{ "hospital_name": "Montclair Hospital Medical Center", "last_updated_on": "2026-03-17", "version": "3.0", "location_name": [ "Montclair Hospital Medical Center" ], "hospital_address": [ "5000 San Bernardino Street Montclair, CA 91763" ], "license_information": { "license_number": "202898771", "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": "Gail Aviado" }, "type_2_npi": [ "1992721161" ], "standard_charge_information": [ { "description": "Abd Paracentesis", "code_information": [ { "code": "49082", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3548.13, "discounted_cash": 1160, "minimum": 58.45, "maximum": 5070.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.75 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.5 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2321.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Abd Paracentesis W/Imaging", "code_information": [ { "code": "49083", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5281, "discounted_cash": 1160, "minimum": 89.72, "maximum": 6232.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.09 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 94.34 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 89.72 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2321.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 89.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 1", "code_information": [ { "code": "2511", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3970.07, "maximum": 5359.59, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5359.59, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3970.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 2", "code_information": [ { "code": "2512", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5154.21, "maximum": 6958.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6958.18, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5154.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 3", "code_information": [ { "code": "2513", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6680.75, "maximum": 9019.01, "payers_information": [ { "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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6680.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9019.01, "additional_payer_notes": "135% of State Medicaid Rates" } ] } ] }, { "description": "ABDOMINAL PAIN - SOI : 4", "code_information": [ { "code": "2514", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10145.16, "maximum": 13695.97, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13695.97, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10145.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY", "code_information": [ { "code": "770", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10287, "minimum": 8494.7325, "maximum": 20575.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 12859.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10327.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11685.41 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 20575.54, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10287.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 13374.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14402.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10287.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12859.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18641.44, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 14464.6, "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": 15020.14, "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": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10839.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10287.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10287.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16460.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10430.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10287.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10459.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10225.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19308.41 } ] } ] }, { "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": 6128.55, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6128.55, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4857.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4539.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 2", "code_information": [ { "code": "5432", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5975.15, "maximum": 8066.45, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8066.45, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 3", "code_information": [ { "code": "5433", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9671.72, "maximum": 13056.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13056.82, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10348.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9671.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY- SOI : 4", "code_information": [ { "code": "5434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17669.85, "maximum": 23854.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23854.3, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17669.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WITHOUT D&C", "code_information": [ { "code": "779", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8732, "minimum": 5620.56, "maximum": 31854.9225, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10915.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8767.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14472.53 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17465.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8732.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11352.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12225.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8732.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10915.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15823.58, "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": 12278.12, "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": 12749.68, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9201.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8732.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8732.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13972.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8854.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8732.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5620.56 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8680.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16774.63 } ] } ] }, { "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": 3946.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3946.64, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2923.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 2", "code_information": [ { "code": "5642", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3745.55, "maximum": 5056.49, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5056.49, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3745.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 3", "code_information": [ { "code": "5643", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6403.11, "maximum": 8644.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8644.2, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6403.11, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ABORTION WO D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY - SOI : 4", "code_information": [ { "code": "5644", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14390.43, "maximum": 19427.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19427.08, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14390.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 1", "code_information": [ { "code": "1931", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8140.51, "maximum": 10989.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10989.69, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8140.51, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 2", "code_information": [ { "code": "1932", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9819.71, "maximum": 13256.61, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.61, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9819.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 3", "code_information": [ { "code": "1933", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13200.37, "maximum": 17820.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17820.5, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13200.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE & SUBACUTE ENDOCARDITIS - SOI : 4", "code_information": [ { "code": "1934", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18754.23, "maximum": 25318.21, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25318.21, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18754.23, "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": 9878, "minimum": 5936, "maximum": 19756.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 12347.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9916.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13966.31 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19756.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9878.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12841.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13829.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9878.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12347.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17899.44, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 13888.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14422.29, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10407.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9878.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9878.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15805.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10015.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9878.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8049.14 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9818.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17201.71 } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH CC", "code_information": [ { "code": "289", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17072, "minimum": 9436.21, "maximum": 34145.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 21341.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 17136.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21619.54 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 34145.7, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17072.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 22194.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23901.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17072.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21341.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30936, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 24004.43, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24926.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17985.02, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 17072.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17072.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27316.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 17306.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17072.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9436.21 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16967, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28293.28 } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC", "code_information": [ { "code": "288", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26701, "minimum": 22147.0275, "maximum": 53402.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 33376.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 26798.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37936.98 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 53402.54, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 26701.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 34711.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 37381.78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 26701.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 33376.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 48382.7, "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": 37541.99, "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": 38983.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28125.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 26701.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26701.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 42722.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 27064.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26701.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 36637.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 26533.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49015.73 } ] } ] }, { "description": "ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CCMCC", "code_information": [ { "code": "290", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9584, "minimum": 9526.77, "maximum": 19168.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11980.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9622.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15875.6 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19168.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9584.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12459.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13418.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9584.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11980.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17366.95, "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": 13475.68, "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": 13993.24, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10098.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9584.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9584.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15335.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9717.31, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9584.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13315.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9526.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17567.78 } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 1", "code_information": [ { "code": "7561", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3331.89, "maximum": 4498.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4498.05, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3331.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 2", "code_information": [ { "code": "7562", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4969.75, "maximum": 6709.16, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6709.16, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4969.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 3", "code_information": [ { "code": "7563", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7029.52, "maximum": 9489.85, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9489.85, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7029.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE ANXIETY & DELIRIUM STATES - SOI : 4", "code_information": [ { "code": "7564", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10975.22, "maximum": 14816.55, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14816.55, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10975.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 1", "code_information": [ { "code": "1451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3855.58, "maximum": 5205.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5205.03, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3855.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 2", "code_information": [ { "code": "1452", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4873.28, "maximum": 6578.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6578.93, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4873.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 3", "code_information": [ { "code": "1453", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6782.52, "maximum": 9156.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9156.4, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6782.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE BRONCHITIS AND RELATED SYMPTOMS - SOI : 4", "code_information": [ { "code": "1454", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10920.09, "maximum": 14742.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14742.12, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11684.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10920.09, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 1", "code_information": [ { "code": "4691", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4013.54, "maximum": 5418.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5418.28, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4013.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 2", "code_information": [ { "code": "4692", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5463.76, "maximum": 7376.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7376.08, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5463.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE KIDNEY INJURY - SOI : 3", "code_information": [ { "code": "4693", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8886.82, "maximum": 11997.21, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11997.21, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8886.82, "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": 23045.57, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23045.57, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17070.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6901", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8594.23, "maximum": 11602.21, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11602.21, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8594.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15211.37, "maximum": 20535.35, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20535.35, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15211.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6903", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25746.65, "maximum": 34757.98, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34757.98, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25746.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6904", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45078.63, "maximum": 60856.15, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60856.15, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45078.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC", "code_information": [ { "code": "835", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20723, "minimum": 15823.0125, "maximum": 41447.24, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 25904.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 20800.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32706.57 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 41447.24, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20723.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 26940.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29013.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20723.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25904.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37551.2, "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": 29137.41, "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": 30256.49, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21829.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 20723.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20723.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33157.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 21006.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20723.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24727 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20594.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38327.91 } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC", "code_information": [ { "code": "834", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 53522, "minimum": 27063.255, "maximum": 111585, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56373.24, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 53522.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53522.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 85636.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 54245.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53522.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 111585 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99185.3 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 66903.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 53714.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 81916.38 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 107045.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 53522.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 69579.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 74931.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 53522.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 66903.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 96983.06, "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": 75252.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 78143.08, "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": 53182.3, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "836", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12376, "minimum": 10800, "maximum": 62335.7925, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 15470.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12424.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20656.86 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 24753.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12376.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 16089.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17327.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12376.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15470.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22426.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 17401.61, "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": 18069.95, "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": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13039.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12376.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12376.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19802.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12547.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12376.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17283.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12301.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22802.23 } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CCMCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11835, "minimum": 5915.86, "maximum": 23670.36, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14793.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11880.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18744.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 23670.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11835.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15385.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16569.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11835.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14793.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21445.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 16640.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17279.36, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12468.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11835.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11835.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18936.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11998.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11835.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5915.86 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11763.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20873.18 } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITHOUT CCMCC", "code_information": [ { "code": "122", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8197, "minimum": 3793.6, "maximum": 16395.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10247.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8230.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10892.43 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16395.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8197.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10657.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11477.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8197.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10247.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14854.61, "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": 11526.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11968.95, "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": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8638.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8197.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8197.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13116.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8312.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8197.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 3793.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8149.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12171.84 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 1", "code_information": [ { "code": "1901", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6639.41, "maximum": 8963.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8963.2, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6639.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION - SOI : 2", "code_information": [ { "code": "1902", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7316.81, "maximum": 9877.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9877.69, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "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": 12815.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12815.82, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9493.2, "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": 20435.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20435.18, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15137.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC", "code_information": [ { "code": "281", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9482, "minimum": 9382.2225, "maximum": 18964.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11852.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9519.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13357.68 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18964.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9482.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12326.96, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13275.19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9482.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11852.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17181.89, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 13332.09, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13844.13, "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": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9990.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9482.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9482.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15171.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9613.8, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9482.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12584.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16541.35 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC", "code_information": [ { "code": "280", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16082, "minimum": 11925.3225, "maximum": 32164.72, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20102.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16142.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23211.35 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 32164.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16082.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20907.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22515.3, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16082.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20102.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29141.24, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 22611.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23480.25, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16941.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16082.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16082.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25731.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16302.56, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16082.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18666.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15982.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29454.3 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CCMCC", "code_information": [ { "code": "282", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7593, "minimum": 7548.95, "maximum": 25700.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9492.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7624.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10506.19 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 15187.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7593.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9871.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10631.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7593.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9492.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13759.93, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10676.85, "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": 11086.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8001.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7593.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7593.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12150.05, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7699.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7593.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11287.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7548.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13011.64 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC", "code_information": [ { "code": "284", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7296, "minimum": 7200, "maximum": 14592.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9120.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7325.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10822.21 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14592.12, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7296.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9484.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10214.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7296.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9120.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13220.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10258.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10652.25, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7688.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7296.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7296.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11673.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7398.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7296.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10078.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7253.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13296.96 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19711, "minimum": 8981.295, "maximum": 39423.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24639.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19784.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28842.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 39423.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19711.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 25625.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27596.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19711.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24639.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35718, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 27714.96, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28779.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20764.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19711.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19711.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31539.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19980.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19711.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34648.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19589.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35088.91 } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CCMCC", "code_information": [ { "code": "285", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6397, "minimum": 5850, "maximum": 28711.08, "payers_information": [ { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 12794.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6397.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8316.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8955.94, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6397.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 7996.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11591.55, "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": 8994.32, "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": 9339.77, "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": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6741.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6397.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6397.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10235.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6487.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6397.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7636.21 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10074.11 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 7996.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6423.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6359.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7149.94 } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 1", "code_information": [ { "code": "7551", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2180.63, "maximum": 2943.85, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2943.85, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2180.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 2", "code_information": [ { "code": "7552", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2936.48, "maximum": 3964.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3964.25, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2936.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 3", "code_information": [ { "code": "7553", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5442.55, "maximum": 7347.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7347.44, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5823.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5442.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES - SOI : 4", "code_information": [ { "code": "7554", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8638.75, "maximum": 11662.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11662.31, "additional_payer_notes": "135% 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": "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8638.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITH CCMCC", "code_information": [ { "code": "614", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21744, "minimum": 12150, "maximum": 43489.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 27181.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 21825.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32953.82 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 43489.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21744.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 28268.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30442.92, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21744.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27181.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39401.83, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 30573.39, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31747.61, "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": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22905.54, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 21744.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21744.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34791.9, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 22041.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21744.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33312.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21609, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40895.79 } ] } ] }, { "description": "ADRENAL AND PITUITARY PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "615", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14109, "minimum": 6750, "maximum": 45249.015, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17636.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14162.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21522.98 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 28218.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14109.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18341.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19752.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14109.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17636.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25565.65, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 19837.37, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20599.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14863.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14109.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14109.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22574.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14302.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14109.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20201.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14022.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25714.64 } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 1", "code_information": [ { "code": "4011", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10090.03, "maximum": 13621.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13621.54, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10090.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 2", "code_information": [ { "code": "4012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13076.33, "maximum": 17653.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17653.05, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13076.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 3", "code_information": [ { "code": "4013", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24086.53, "maximum": 32516.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32516.82, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24086.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ADRENAL PROCEDURES - SOI : 4", "code_information": [ { "code": "4014", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 45294.89, "maximum": 61148.1, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61148.1, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45294.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AFTERCARE WITH CCMCC", "code_information": [ { "code": "949", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12089, "minimum": 8144.4075, "maximum": 30226.2, "payers_information": [ { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 24179.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12089.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15716.42, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16925.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12089.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15111.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21906.26, "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": 16997.91, "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": 17650.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12736.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12089.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12089.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19343.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12256.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12089.55, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30226.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19362.25 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 15111.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12135.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12015.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15695.64 } ] } ] }, { "description": "AFTERCARE WITHOUT CCMCC", "code_information": [ { "code": "950", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6674, "minimum": 6635.67, "maximum": 24131.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8343.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6702.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9343.06 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 13349.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6674.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8676.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9344.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6674.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8343.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12094.36, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 9384.47, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9744.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7033.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6674.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6674.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10679.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6768.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6674.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24131.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6635.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10517.34 } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11476, "minimum": 10430.6025, "maximum": 22953.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14345.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11520.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16563.23 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 22953.5, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11476.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14919.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16067.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11476.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14345.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20795.87, "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": 16136.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16756.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12091.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11476.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11476.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18362.8, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11635.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11476.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19111.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11406.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20433.54 } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "559", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18595, "minimum": 14611.1475, "maximum": 37190.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 23244.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 18664.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27073.81 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 37190.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18595.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 24173.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26033.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18595.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23244.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33694.52, "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": 26144.87, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27149.01, "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": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19588.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 18595.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18595.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29752.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18849.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18595.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25247.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18479.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33310.6 } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "561", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8372, "minimum": 8322.46, "maximum": 18486.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10465.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8405.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11414.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16744.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8372.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10884, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11721.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8372.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10465.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15170.63, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 11771.47, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12223.57, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8821.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8372.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8372.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13395.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8488.91, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8372.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12242.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8322.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14671.52 } ] } ] }, { "description": "AICD GENERATOR PROCEDURES", "code_information": [ { "code": "245", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44586, "minimum": 19350, "maximum": 89172.1, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 55732.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 44746.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 66296.82 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 89172.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 44586.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 57961.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 62420.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 44586.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 55732.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 80789.92, "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": 62687.99, "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": 65095.63, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46961.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 44586.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44586.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 71337.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 45189.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44586.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 66465.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 44303.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87691.77 } ] } ] }, { "description": "AICD LEAD PROCEDURES", "code_information": [ { "code": "265", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35488, "minimum": 18450, "maximum": 79515.99, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 44360.68, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 35616.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51705.78 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 70977.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 35488.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 46135.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 49683.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 35488.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 44360.68, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 64305.23, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 49896.89, "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": 51813.27, "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": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37380.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 35488.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 35488.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 56781.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 35969.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 35488.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 48517.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 35264.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64012.05 } ] } ] }, { "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": 5206.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5206.46, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3856.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 2", "code_information": [ { "code": "7722", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4532.99, "maximum": 6119.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6119.54, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4532.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 3", "code_information": [ { "code": "7723", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6860.97, "maximum": 9262.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9262.31, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6860.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL & DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY - SOI : 4", "code_information": [ { "code": "7724", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18947.17, "maximum": 25578.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25578.68, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18947.17, "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": 4439.38, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4439.38, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3288.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 2", "code_information": [ { "code": "7752", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4746.07, "maximum": 6407.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6407.19, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4746.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7753", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8305.88, "maximum": 11212.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11212.94, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8305.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7754", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19303.36, "maximum": 26059.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26059.54, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19303.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY", "code_information": [ { "code": "895", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14266, "minimum": 9018.37, "maximum": 34200, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17832.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14320.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23537.61 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 28532.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14266.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18545.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19972.58, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14266.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17832.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25850.23, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 20058.18, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20828.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15029.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14266.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14266.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22825.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14461.97, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9018.37 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14178.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25982.02 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC", "code_information": [ { "code": "896", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17440, "minimum": 10176, "maximum": 34881.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 21801.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 17506.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26014.56 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 34881.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17440.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 22673.2, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24417.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17440.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21801.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31602.95, "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": 24521.93, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 25463.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18372.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 17440.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17440.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27905.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 17679.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17440.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14364.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17332.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31955.78 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC", "code_information": [ { "code": "897", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9132, "minimum": 6996, "maximum": 18265.04, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11415.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9168.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12517.89 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18265.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9132.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11872.28, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12785.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9132.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11415.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16548.13, "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": 12840.32, "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": 13333.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9622.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9132.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9132.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14612.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9259.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9132.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9077.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15830.74 } ] } ] }, { "description": "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA", "code_information": [ { "code": "894", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6570, "minimum": 4452, "maximum": 13141.06, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8213.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6597.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8405.24 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 13141.06, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6570.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8541.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9198.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6570.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8213.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11905.8, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 9238.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9592.97, "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": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6924.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6570.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6570.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10512.85, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6662.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6570.53, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4727.29 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6532.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11199.24 } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 1", "code_information": [ { "code": "2801", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4881.76, "maximum": 6590.38, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6590.38, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4881.76, "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": 8661.24, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8661.24, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6415.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALCOHOLIC LIVER DISEASE - SOI : 3", "code_information": [ { "code": "2803", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9753.98, "maximum": 13167.87, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13167.87, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9753.98, "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": 25972.23, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25972.23, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19238.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 1", "code_information": [ { "code": "8111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2829.41, "maximum": 3819.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3819.7, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2829.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 2", "code_information": [ { "code": "8112", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4082.45, "maximum": 5511.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.31, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4082.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS - SOI : 3", "code_information": [ { "code": "8113", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8023.9, "maximum": 10832.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10832.26, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8023.9, "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": 20469.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20469.52, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15162.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16829, "minimum": 8645.2425, "maximum": 33658.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16892.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25954.57 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 33658.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16829.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21877.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23560.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16829.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21036.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30494.31, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 23661.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24570.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17728.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16829.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16829.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26926.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 17059.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16829.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18867.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16724.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31185.96 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 21036.36, "additional_payer_notes": "125.00% of Medicare Rates" } ] } ] }, { "description": "ALLERGIC REACTIONS WITHOUT MCC", "code_information": [ { "code": "916", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7046, "minimum": 5412.25, "maximum": 20349.99, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8808.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7075.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9638.6 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14093.02, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7046.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9160.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9865.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7046.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8808.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12768.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 9907.39, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10287.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7425.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7046.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7046.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11274.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7145.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7046.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5412.25 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7005.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11917.02 } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT", "code_information": [ { "code": "014", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 116420, "minimum": 115676, "maximum": 235106.8223, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 145526.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 116832.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 167679.12 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 232841.98, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 116420.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 151347.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 162989.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 116420.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 145526.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 210954.83, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 163687.91, "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": 169974.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 122616.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 116420.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 116420.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 186273.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 117989.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 116420.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 143918 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 115676, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 235106.82 } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 1", "code_information": [ { "code": "0071", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55309.66, "maximum": 74668.04, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74668.04, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55309.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 2", "code_information": [ { "code": "0072", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66446.01, "maximum": 89702.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89702.11, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66446.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 3", "code_information": [ { "code": "0073", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 89273.14, "maximum": 120518.74, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 120518.74, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89273.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALLOGENEIC BONE MARROW TRANSPLANT- SOI : 4", "code_information": [ { "code": "0074", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 149835.59, "maximum": 202278.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 202278.05, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 160324.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 149835.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 1", "code_information": [ { "code": "0521", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4892.36, "maximum": 6604.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6604.69, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4892.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 2", "code_information": [ { "code": "0522", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6485.69, "maximum": 8755.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8755.68, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6485.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 3", "code_information": [ { "code": "0523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9100.96, "maximum": 12286.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12286.3, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9100.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ALTERATION IN CONSCIOUSNESS - SOI : 4", "code_information": [ { "code": "0524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15262.26, "maximum": 20604.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20604.05, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15262.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC", "code_information": [ { "code": "240", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 28091, "minimum": 17962.59, "maximum": 56183.24, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 35114.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 28194.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41100.1 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 56183.24, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 28091.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 36519.11, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 39328.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 28091.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 35114.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 50902.02, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 39496.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 41013.77, "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": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 29589.79, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 28091.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 28091.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 44946.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 28473.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 28091.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25535.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 27914.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 52258.32 } ] } ] }, { "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": 48047, "minimum": 36985.2375, "maximum": 96095.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 60059.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 48220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70326.07 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 96095.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 48047.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 62462.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 67267.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 48047.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 60059.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 87062.92, "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": 67555.45, "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": 70150.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 50607.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 48047.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 48047.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 76876.75, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 48697.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 48047.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 48490.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 47742.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90385.26 } ] } ] }, { "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": 13965, "minimum": 13879.7, "maximum": 41426.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17456.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14018.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20394.97 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 27931.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13965.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18155.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19551.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13965.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17456.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25305.52, "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": 19635.52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20389.66, "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": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14712.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13965.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13965.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22344.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14157.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13965.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20536.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13879.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27094.58 } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "475", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22553, "minimum": 22412.2, "maximum": 45106.66, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 28191.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 22636.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31378.11 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 45106.66, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22553.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 29319.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 31574.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 22553.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 28191.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 40866.63, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 31709.98, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32927.86, "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": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23756.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 22553.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22553.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36085.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 22860.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22553.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25620.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 22412.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38711.93 } ] } ] }, { "description": "AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "474", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41989, "minimum": 41723.2, "maximum": 83978.76, "payers_information": [ { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 67183.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 42557.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 41989.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 70681.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80476.24 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 52486.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 42140.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62952.28 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 83978.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 41989.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 54586.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 58785.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 41989.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 52486.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 76084.76, "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": 59037.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 61304.49, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44226.59, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 41989.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 41989.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41723.2, "additional_payer_notes": "100.00% 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": 11998, "minimum": 10542.7, "maximum": 23996.04, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14997.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12044.05, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17218.68 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 23996.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11998.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15597.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16797.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11998.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14997.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21740.41, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 16869.22, "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": 17517.11, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12640.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11998.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11998.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19196.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12163.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11998.02, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10542.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11924.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20871.39 } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 1", "code_information": [ { "code": "3051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9407.33, "maximum": 12699.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12699.9, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9407.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 2", "code_information": [ { "code": "3052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12581.27, "maximum": 16984.71, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16984.71, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care 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": 24976.17, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24976.17, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18500.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB EXCEPT TOES - SOI : 4", "code_information": [ { "code": "3054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 31219.94, "maximum": 42146.92, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42146.92, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31219.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC", "code_information": [ { "code": "617", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18647, "minimum": 18402.4425, "maximum": 37294.48, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 23309.05, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 18716.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29034.3 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 37294.48, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18647.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 24241.41, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26106.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18647.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23309.05, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33788.8, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 26218.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27224.97, "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": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19643.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 18647.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18647.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29835.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18901.93, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18647.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18626.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18531.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34661.83 } ] } ] }, { "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": 34228, "minimum": 24267.1425, "maximum": 69355.9563, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 42785.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 34352.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57903.28 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 68456.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34228.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 44496.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 47919.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 34228.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 42785.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 62021.61, "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": 48124.93, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 49973.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36052.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 34228.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34228.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 54765.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 34692.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34228.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 30085.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 34012, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69355.96 } ] } ] }, { "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": 14292, "minimum": 14204.2, "maximum": 37464.015, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15056.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14292.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14292.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22867.44, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14488.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14292.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16935.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22342.85 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17865.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14346.24, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16993.37 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 28584.3, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14292.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18579.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20009.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14204.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14292.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17865.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25897.38, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 20094.76, "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": 20866.54, "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": 14204.2, "additional_payer_notes": "100.00% 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": 9001.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9001.84, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6668.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 2", "code_information": [ { "code": "2262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8216.84, "maximum": 11092.73, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11092.73, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8216.84, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 3", "code_information": [ { "code": "2263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12875.97, "maximum": 17382.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17382.56, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12875.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND PERINEAL PROCEDURES- SOI : 4", "code_information": [ { "code": "2264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21704.49, "maximum": 29301.06, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29301.06, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21704.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH CC", "code_information": [ { "code": "348", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13237, "minimum": 13156, "maximum": 32332.4025, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16546.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13287.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19040.18 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 26474.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13237.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 17208.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18531.94, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13237.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16546.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23985.63, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 18611.36, "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": 19326.17, "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": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13945.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13237.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13237.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21179.36, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13419.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13237.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16465.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13156, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22590.48 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITH MCC", "code_information": [ { "code": "347", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 22745, "minimum": 11296.035, "maximum": 45490.14, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 28431.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 22828.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37294.7 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 45490.14, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 22745.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 29568.59, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 31843.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 22745.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 28431.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41214.07, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 31979.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 33207.8, "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": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23958.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 22745.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 22745.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36392.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 23054.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 22745.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32190.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 22602.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42471.33 } ] } ] }, { "description": "ANAL AND STOMAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "349", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9014, "minimum": 7650, "maximum": 19780.3875, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11268.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9050.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14276.48 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18029.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9014.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11719.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12620.96, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9014.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11268.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16335.13, "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": 12675.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13161.86, "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": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9498.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9014.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9014.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14423.95, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9140.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9014.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9042.88 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8960.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15807.42 } ] } ] }, { "description": "ANES 1ST 60 MIN", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10842.9, "minimum": 146.17, "maximum": 10842.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 211.95 }, { "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": "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 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] }, { "setting": "outpatient", "gross_charge": 10842.91, "minimum": 146.17, "maximum": 10842.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 211.95 }, { "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": "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 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.17 } ] } ] }, { "description": "ANGINA PECTORIS", "code_information": [ { "code": "311", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7389, "minimum": 7346, "maximum": 27055.47, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9236.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7419.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10213.58 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14779.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7389.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9606.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10345.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7389.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9236.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13389.81, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10389.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10788.7, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7786.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7389.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7389.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11823.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7492.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7389.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8089.57 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7346, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12530.73 } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 1", "code_information": [ { "code": "1981", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3984.92, "maximum": 5379.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5379.64, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3984.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 2", "code_information": [ { "code": "1982", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4834.06, "maximum": 6525.98, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6525.98, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4834.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS - SOI : 3", "code_information": [ { "code": "1983", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6257.77, "maximum": 8447.99, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8447.99, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6257.77, "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": 14707.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14707.78, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10894.65, "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": 5704.51, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5704.51, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4225.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 2", "code_information": [ { "code": "0592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7339.07, "maximum": 9907.74, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9907.74, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7339.07, "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": 14497.39, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14497.39, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11490.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10738.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANOXIC & OTHER SEVERE BRAIN DAMAGE - SOI : 4", "code_information": [ { "code": "0594", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16561.94, "maximum": 22358.62, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22358.62, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16561.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5471", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4360.09, "maximum": 5886.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5886.12, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4360.09, "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": 11564.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11564.42, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8566.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5473", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13219.02, "maximum": 17845.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17845.68, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13219.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITH O.R. PROCEDURE- SOI : 4", "code_information": [ { "code": "5474", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25639.21, "maximum": 34612.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34612.93, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25639.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 1", "code_information": [ { "code": "5661", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2268.08, "maximum": 3061.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3061.91, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2268.08, "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": 4385.85, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4385.85, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3248.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 3", "code_information": [ { "code": "5663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6022.96, "maximum": 8131, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8131, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6022.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTEPARTUM WITHOUT O.R. PROCEDURE- SOI : 4", "code_information": [ { "code": "5664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13254.22, "maximum": 17893.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17893.2, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13254.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ANTERIOR COLPORRHAPHY, REPAIR CYSTOCELE", "code_information": [ { "code": "57240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12323.7, "discounted_cash": 6402, "minimum": 617.8, "maximum": 12323.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 895.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 648.69 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12323.68, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 9001.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9347.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 661.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 12323.68, "discounted_cash": 6402, "minimum": 617.8, "maximum": 12323.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 895.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 648.69 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12323.68, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 9001.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9347.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 661.05 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 617.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC", "code_information": [ { "code": "268", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 66896, "minimum": 18488.9, "maximum": 133792.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 83620.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 67134.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 100287.94 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 133792.54, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 66896.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 86965.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 93654.78, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 66896.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 83620.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 121216.04, "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": 94056.16, "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": 97668.55, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 70457.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 66896.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 66896.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 107034.03, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 67799.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 66896.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18488.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 66469.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 119647.55 } ] } ] }, { "description": "AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC", "code_information": [ { "code": "269", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41317, "minimum": 6750, "maximum": 82635.62, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 51647.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 41466.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60842.55 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 82635.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 41317.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 53713.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 57844.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 41317.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 51647.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 74867.87, "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": 58092.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 60324, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43519.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 41317.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 41317.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 66108.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 41877.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 41317.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8404.48 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 41056, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74662.18 } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 1", "code_information": [ { "code": "2331", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8727.8, "maximum": 11782.53, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11782.53, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8727.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2332", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11244.48, "maximum": 15180.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15180.05, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11244.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2333", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15997.97, "maximum": 21597.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21597.26, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15997.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS - SOI : 4", "code_information": [ { "code": "2334", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24117.27, "maximum": 32558.31, "payers_information": [ { "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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24117.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32558.31, "additional_payer_notes": "135% 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" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 1", "code_information": [ { "code": "2341", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7065.57, "maximum": 9538.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9538.52, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7065.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 2", "code_information": [ { "code": "2342", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9012.97, "maximum": 12167.51, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12167.51, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9012.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 3", "code_information": [ { "code": "2343", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13392.24, "maximum": 18079.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18079.52, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13392.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS - SOI : 4", "code_information": [ { "code": "2344", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21609.08, "maximum": 29172.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29172.26, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21609.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "APPENDIX PROCEDURES WITH CC", "code_information": [ { "code": "398", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15210, "minimum": 13500, "maximum": 32045.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19012.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15267.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22140.39 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 30420.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15210.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 19773.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21294.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15210.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19012.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27561.21, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 21385.79, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22207.15, "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": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16023.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15210.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15210.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24336.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 15418.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15210.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 32045.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15116.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27153.8 } ] } ] }, { "description": "APPENDIX PROCEDURES WITH MCC", "code_information": [ { "code": "397", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23701, "minimum": 22950, "maximum": 47403.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 29627.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 23788.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32868.96 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 47403.68, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 23701.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 30812.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 33182.58, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23701.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 29627.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42947.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 33324.79, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 34604.69, "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": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24966.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 23701.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23701.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37922.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 24024.47, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23701.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35638.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23553.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44463.18 } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11655, "minimum": 8550, "maximum": 23311.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14569.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11700.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16285.25 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 23311.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11655.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15152.76, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16318.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11655.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14569.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21120.62, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 16388.29, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17017.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12280.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11655.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11655.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18649.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11816.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11655.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20612.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11585, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20166.16 } ] } ] }, { "description": "ARTHROSCOPY", "code_information": [ { "code": "509", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18000, "maximum": 39190.9875, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19986.78 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23892.6 }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31523.31 } ] } ] }, { "description": "ASTHMA - SOI : 1", "code_information": [ { "code": "1411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3243.91, "maximum": 4379.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4379.28, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3470.98, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3243.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 2", "code_information": [ { "code": "1412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4806.49, "maximum": 6488.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6488.76, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4806.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 3", "code_information": [ { "code": "1413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6672.27, "maximum": 9007.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9007.56, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6672.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ASTHMA - SOI : 4", "code_information": [ { "code": "1414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11195.72, "maximum": 15114.22, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15114.22, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11979.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11195.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ATHEROSCLEROSIS WITH MCC", "code_information": [ { "code": "302", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12156, "minimum": 9797.4225, "maximum": 24312.06, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 15195.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12202.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16402.3 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 24312.06, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12156.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15802.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17018.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12156.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15195.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22026.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 17091.38, "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": 17747.8, "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": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12806.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12156.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12156.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19449.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12323.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12156.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15822.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12081.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20874.98 } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7112, "minimum": 6383.93, "maximum": 20446.005, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8891.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7141.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9628.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14225.98, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7112.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9246.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9958.19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7112.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8891.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12888.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10000.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10384.97, "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": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7495.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7112.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7112.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11380.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7212.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7112.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6383.93 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7071.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12065.96 } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 1", "code_information": [ { "code": "0081", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29173.95, "maximum": 39384.83, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39384.83, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31216.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29173.95, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 2", "code_information": [ { "code": "0082", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 34562.44, "maximum": 46659.29, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46659.29, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34562.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 3", "code_information": [ { "code": "0083", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 42705.07, "maximum": 57651.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57651.84, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45694.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42705.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT OR T-CELL IMMUNOTHERAPY- SOI : 4", "code_information": [ { "code": "0084", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 65108.16, "maximum": 87896.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 87896.02, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 69665.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65108.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITH CCMCC", "code_information": [ { "code": "016", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57760, "minimum": 57392.6, "maximum": 115520.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 72200.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 57966.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90372.83 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 115520.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 57760.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 75088.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 80864.29, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 57760.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 72200.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 104661.5, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 81210.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 84329.91, "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": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60836.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 57760.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57760.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 92416.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 58540.45, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57760.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 61546.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 57392.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 108311.93 } ] } ] }, { "description": "AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CCMCC", "code_information": [ { "code": "017", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52967, "minimum": 52630.9, "maximum": 108311.9319, "payers_information": [ { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 55788.75, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 52967.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52967.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 84748.29, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 53683.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52967.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 82094.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 108311.93 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 66209.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 53157.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90372.83 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 105935.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 52967.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 68857.98, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 74154.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 52967.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 66209.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 95977.44, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 74472.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 77332.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52630.9, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19898, "minimum": 14400, "maximum": 39797.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24873.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19972.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28801.68 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 39797.7, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19898.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 25868.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27858.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19898.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24873.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36056.72, "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": 27977.78, "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": 29052.32, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20961.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19898.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19898.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31838.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 20170.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19898.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27306.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19774.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35385 } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR", "code_information": [ { "code": "518", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 36636, "minimum": 24300, "maximum": 73272.16, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 45795.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 36768.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53427.8 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 73272.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 36636.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 47626.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 51290.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 36636.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 45795.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 66384.58, "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": 51510.33, "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": 53488.68, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 38588.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 36636.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 36636.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 58617.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 37132.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 36636.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 40378.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 36404.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64313.52 } ] } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "520", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15020, "minimum": 9000, "maximum": 37240.845, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 18775.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15077.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20943.61 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 30041.14, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15020.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 19526.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21028.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15020.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18775.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27217.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 21118.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21930.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15823.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15020.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15020.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24032.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 15226.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15020.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21392.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14927.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25718.23 } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 1", "code_information": [ { "code": "0491", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8313.3, "maximum": 11222.95, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11222.95, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8895.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8313.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 2", "code_information": [ { "code": "0492", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11038.82, "maximum": 14902.41, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14902.41, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11811.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11038.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 3", "code_information": [ { "code": "0493", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15618.45, "maximum": 21084.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21084.91, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16711.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15618.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM - SOI : 4", "code_information": [ { "code": "0494", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25716.97, "maximum": 34717.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34717.91, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27517.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25716.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC", "code_information": [ { "code": "095", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25477, "minimum": 24750, "maximum": 50955.2, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 46165.41, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 35821.51, "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": 37197.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26836.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40764.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 25824.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 31210.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43016.84 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 31847, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 25570.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34882.13 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 50955.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 33120.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 35668.64, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 31847, "additional_payer_notes": "125.00% of Medicare Rates" } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC", "code_information": [ { "code": "094", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34536, "minimum": 34318.4, "maximum": 69073.16, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 43170.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 34661.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 53002.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 69073.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34536.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 44897.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 48351.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 34536.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 43170.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 62580.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 48558.43, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 50423.41, "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": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36377.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 34536.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34536.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55258.53, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 35004.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34536.58, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 40433.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 34318.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 65474.54 } ] } ] }, { "description": "BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CCMCC", "code_information": [ { "code": "096", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25477, "minimum": 17677.14, "maximum": 50955.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 31847, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 25570.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31890.18 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 50955.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 33120.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 35668.64, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 31847, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 46165.41, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 35821.51, "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": 37197.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26836.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40764.16, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 25824.05, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25477.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23865.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25317.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43016.84 } ] } ] }, { "description": "BEHAVIORAL AND DEVELOPMENTAL DISORDERS", "code_information": [ { "code": "886", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20622, "minimum": 9752, "maximum": 41244.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 25778.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 20698.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24604.17 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 41244.9, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20622.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 26809.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 28871.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20622.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25778.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37367.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 28995.16, "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": 30108.78, "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": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21723.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 20622.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20622.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32995.92, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 20903.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20622.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15043.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20493.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32237.51 } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 1", "code_information": [ { "code": "7581", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3371.12, "maximum": 4551.01, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4551.01, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3607.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3371.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 2", "code_information": [ { "code": "7582", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4174.67, "maximum": 5635.8, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5635.8, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4466.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4174.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 3", "code_information": [ { "code": "7583", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6793.12, "maximum": 9170.71, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9170.71, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7268.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6793.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BEHAVIORAL DISORDERS - SOI : 4", "code_information": [ { "code": "7584", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22778.37, "maximum": 30750.8, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30750.8, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24372.86, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22778.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITH MCC", "code_information": [ { "code": "725", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11901, "minimum": 9367.95, "maximum": 23803.32, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14877.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11947.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18155.03 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 23803.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11901.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15472.16, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16662.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11901.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14877.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21565.81, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 16733.73, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17376.42, "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": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12538.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11901.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11901.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19042.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12065.68, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11901.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17172.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11829.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22656.88 } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7583, "minimum": 4773.85, "maximum": 19240.6275, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9478.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7613.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10693.46 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 15166.38, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7583.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9858.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10616.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7583.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9478.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13740.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10661.97, "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": 11071.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7990.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7583.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7583.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12133.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7689.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7583.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4773.85 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7538.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13357.98 } ] } ] }, { "description": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC", "code_information": [ { "code": "461", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 53841, "minimum": 31950, "maximum": 110120.7496, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 67301.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 54034.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 99758.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 107683.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 53841.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 69994.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 75378.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 53841.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 67301.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 97560.96, "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": 75701.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 78608.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56709.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 53841.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53841.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 86146.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 54569.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53841.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 83465.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 53499.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 110120.75 } ] } ] }, { "description": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC", "code_information": [ { "code": "462", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26256, "minimum": 9900, "maximum": 52512.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 32820.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 26352.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41642.9 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 52512.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 26256.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 34132.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 36758.58, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 26256.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 32820.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 47576.11, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 36916.12, "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": 38333.95, "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": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27656.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 26256.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 26256.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 42009.81, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 26613.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 26256.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29117.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 26091.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51389.8 } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "409", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21605, "minimum": 20700, "maximum": 43210.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 27006.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 21684.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28636.35 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 43210.46, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21605.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 28086.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30247.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21605.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27006.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39148.68, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 30376.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31543.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22758.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 21605.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21605.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34568.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 21899.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21605.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33197.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21470.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37620.9 } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "408", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34981, "minimum": 33750, "maximum": 71465.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 43727.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 35108.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54457.79 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 69963.46, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34981.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 45476.25, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 48974.42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 34981.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 43727.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 63386.89, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 49184.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 51073.33, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36846.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 34981.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34981.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55970.77, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 35455.91, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34981.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 71465.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 34760.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62829.5 } ] } ] }, { "description": "BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "410", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15924, "minimum": 14850, "maximum": 31848.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19905.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22899.72 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 31848.68, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15924.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20701.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22294.08, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15924.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19905.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28854.9, "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": 22389.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23249.54, "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": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16775.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15924.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15924.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25478.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16142.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15924.34, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 25399.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15825.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27833.9 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "478", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24321, "minimum": 23400, "maximum": 48642.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 30401.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 24410.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34874.81 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 48642.78, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24321.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 31617.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 34049.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24321.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30401.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44070.36, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 34195.87, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 35509.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25619.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 24321.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24321.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38914.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 24652.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24321.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24423.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24168.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41965.29 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC", "code_information": [ { "code": "477", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 33912, "minimum": 33698, "maximum": 67824.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 42390.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 34034.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49290.28 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 67824.44, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 33912.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 44085.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 47477.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 33912.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 42390.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 61448.94, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 47680.58, "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": 49511.84, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 35719.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 33912.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 33912.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 54259.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 34371.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 33912.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 54735.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 33698, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61711.55 } ] } ] }, { "description": "BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CCMCC", "code_information": [ { "code": "479", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18537, "minimum": 14850, "maximum": 37074.8, "payers_information": [ { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18790.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20521.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31866.06 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 23171.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 18606.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27271.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 37074.8, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 24098.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25952.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23171.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33589.77, "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": 26063.58, "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": 27064.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19527.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 18537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18537.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18422.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29659.84, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 1", "code_information": [ { "code": "7531", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3406.1, "maximum": 4598.24, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4598.24, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3644.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3406.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 2", "code_information": [ { "code": "7532", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4274.32, "maximum": 5770.33, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5770.33, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4573.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4274.32, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 3", "code_information": [ { "code": "7533", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7316.81, "maximum": 9877.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9877.69, "additional_payer_notes": "135% 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": "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" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7316.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BIPOLAR DISORDERS - SOI : 4", "code_information": [ { "code": "7534", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13656.21, "maximum": 18435.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18435.88, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14612.14, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13656.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Bone biopsy open superficial", "code_information": [ { "code": "20240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3140.66, "discounted_cash": 3717, "minimum": 181.57, "maximum": 3140.66, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 263.28 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 190.65 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 194.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 181.57 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3140.66, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITH MCC", "code_information": [ { "code": "553", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13116, "minimum": 10770.5475, "maximum": 26233.32, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16395.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13166.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19773.17 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 26233.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13116.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 17051.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18363.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13116.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16395.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23767.39, "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": 18442.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19150.32, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13818.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13116.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13116.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20986.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13297.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13116.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17763.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13036.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23435.67 } ] } ] }, { "description": "BONE DISEASES AND ARTHROPATHIES WITHOUT MCC", "code_information": [ { "code": "554", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8624, "minimum": 6815.24, "maximum": 17249.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10780.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8659.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12023.38 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17249.5, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8624.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11212.18, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12074.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8624.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10780.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15628.05, "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": 12126.4, "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": 12592.14, "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": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9087.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8624.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8624.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13799.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8744.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8624.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6815.24 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8573.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14976.58 } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 1", "code_information": [ { "code": "1321", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3163.34, "maximum": 4270.51, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4270.51, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3384.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3163.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 2", "code_information": [ { "code": "1322", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4672.92, "maximum": 6308.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6308.44, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5000.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4672.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 3", "code_information": [ { "code": "1323", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7546.85, "maximum": 10188.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10188.25, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8075.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7546.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD - SOI : 4", "code_information": [ { "code": "1324", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10990.06, "maximum": 14836.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14836.58, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11759.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10990.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 1", "code_information": [ { "code": "0561", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4859.5, "maximum": 6560.33, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6560.33, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5199.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4859.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 2", "code_information": [ { "code": "0562", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6725.27, "maximum": 9079.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9079.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7196.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6725.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 3", "code_information": [ { "code": "0563", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10472.73, "maximum": 14138.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14138.19, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11205.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10472.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRAIN CONTUSIONLACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA - SOI : 4", "code_information": [ { "code": "0564", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17996.26, "maximum": 24294.95, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24294.95, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19256, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17996.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CCMCC", "code_information": [ { "code": "584", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21252, "minimum": 15300, "maximum": 42505.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 26565.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 21331.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28655.37 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 42505.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21252.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 27628.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29753.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21252.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26565.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38509.69, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 29881.14, "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": 31028.78, "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": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22387.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 21252.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21252.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 34004.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 21542.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21252.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 39183.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21119.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36739.82 } ] } ] }, { "description": "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "585", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19213, "minimum": 9900, "maximum": 38427.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24017.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19285.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24637.82 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 38427.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19213.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 24977.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26899.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19213.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24017.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34815.39, "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": 27014.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28052.13, "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": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20239.85, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19213.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19213.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30742.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19476.08, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19213.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37063.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19094.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35621.87 } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 1", "code_information": [ { "code": "3631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9470.93, "maximum": 12785.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12785.76, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10133.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9470.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 2", "code_information": [ { "code": "3632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16578.9, "maximum": 22381.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22381.52, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17739.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16578.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 3", "code_information": [ { "code": "3633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22764.59, "maximum": 30732.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30732.2, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24358.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22764.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BREAST PROCEDURES EXCEPT MASTECTOMY - SOI : 4", "code_information": [ { "code": "3634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27154.46, "maximum": 36658.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36658.52, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29055.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 1", "code_information": [ { "code": "1381", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2414.91, "maximum": 3260.13, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3260.13, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2583.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2414.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 2", "code_information": [ { "code": "1382", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3832.26, "maximum": 5173.55, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5173.55, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4100.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3832.26, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 3", "code_information": [ { "code": "1383", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6974.4, "maximum": 9415.44, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9415.44, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6974.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.61, "additional_payer_notes": "107% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHIOLITIS & RSV PNEUMONIA - SOI : 4", "code_information": [ { "code": "1384", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13157.96, "maximum": 17763.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17763.25, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14079.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13157.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITH CCMCC", "code_information": [ { "code": "202", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9984, "minimum": 8963.24, "maximum": 23757.225, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 12480.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10023.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14008.74 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19968.54, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9984.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12979.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13977.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9984.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12480.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18091.5, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 14037.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14577.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10519.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9984.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9984.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15974.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10122.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9984.27, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8963.24 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9924.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17347.06 } ] } ] }, { "description": "BRONCHITIS AND ASTHMA WITHOUT CCMCC", "code_information": [ { "code": "203", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7082, "minimum": 5793.33, "maximum": 14164.32, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8852.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7111.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10166.76 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14164.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7082.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9206.81, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9915.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7082.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8852.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12832.87, "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": 9957.52, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10339.95, "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": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7463.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7082.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7082.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11331.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7181.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7082.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5793.33 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7040.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12500.22 } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 1", "code_information": [ { "code": "8421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10311.59, "maximum": 13920.65, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13920.65, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11033.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10311.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 2", "code_information": [ { "code": "8422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16502.58, "maximum": 22278.48, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22278.48, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17657.76, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16502.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 3", "code_information": [ { "code": "8423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 32270.5, "maximum": 43565.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43565.18, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34529.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32270.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS - SOI : 4", "code_information": [ { "code": "8424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 92524.47, "maximum": 124908.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 124908.03, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 99001.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 92524.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 1", "code_information": [ { "code": "1961", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3610.7, "maximum": 4874.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4874.44, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3863.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3610.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 2", "code_information": [ { "code": "1962", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4660.2, "maximum": 6291.27, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6291.27, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4986.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4660.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 3", "code_information": [ { "code": "1963", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7462.04, "maximum": 10073.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10073.75, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7984.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7462.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST & SHOCK - SOI : 4", "code_information": [ { "code": "1964", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14134.31, "maximum": 19081.32, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19081.32, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15123.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14134.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH CC", "code_information": [ { "code": "297", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6735, "minimum": 5850, "maximum": 13850.8125, "payers_information": [ { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6735.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6735.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10776.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6829.9, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6735.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9580.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12640.19 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8419.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6762.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10659.81 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 13470.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6735.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8755.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9429.41, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6735.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8419.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12204.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 9469.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9833.52, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6695.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7097.74, "additional_payer_notes": "106.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITH MCC", "code_information": [ { "code": "296", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15675, "minimum": 9000, "maximum": 31351.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19594.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15734.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23455.68 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 31351.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15675.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20378.49, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21946.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15675.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19594.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28404.48, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 22040.12, "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": 22886.61, "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": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16513.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15675.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15675.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25081.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 15890.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15675.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28248.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15578.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29400.47 } ] } ] }, { "description": "CARDIAC ARREST, UNEXPLAINED WITHOUT CCMCC", "code_information": [ { "code": "298", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5011, "minimum": 4950, "maximum": 10023.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 6264.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 5033.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 6433.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 10023.12, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5011.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 6515.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 7016.18, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 5011.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 6264.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 9080.95, "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": 7046.25, "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": 7316.88, "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": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5282.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 5011.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5011.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 8018.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 5083.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5011.56, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6007.75 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 4983.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 7926.14 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 1", "code_information": [ { "code": "2011", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3796.22, "maximum": 5124.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5124.9, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4061.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3796.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 2", "code_information": [ { "code": "2012", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5121.34, "maximum": 6913.81, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6913.81, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5479.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5121.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 3", "code_information": [ { "code": "2013", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7540.49, "maximum": 10179.66, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10179.66, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8068.32, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7540.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS - SOI : 4", "code_information": [ { "code": "2014", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13236.41, "maximum": 17869.15, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17869.15, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14162.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC", "code_information": [ { "code": "309", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7715, "minimum": 6505.24, "maximum": 15430.38, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9643.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7746.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10895.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 15430.38, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10029.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10801.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9643.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13979.92, "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": 10847.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11264.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8129.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12344.3, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7822.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7715.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6505.24 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7669.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13266.46 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC", "code_information": [ { "code": "308", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12227, "minimum": 9107.1525, "maximum": 24454.66, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 15284.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12274.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17588.83 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 24454.66, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12227.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15895.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17118.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12227.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15284.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22155.92, "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": 17191.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17851.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12881.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12227.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12227.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19563.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12395.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12227.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11752.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12152.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21639.42 } ] } ] }, { "description": "CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "310", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6081, "minimum": 5526.21, "maximum": 12162.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 7601.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6106.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8090.69 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 12162.12, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6081.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 7905.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8513.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6081.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 7601.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11018.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 8549.97, "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": 8878.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6408.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6081.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6081.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9729.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6166.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6081.06, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5526.21 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6045.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10040.01 } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 1", "code_information": [ { "code": "1911", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7807.64, "maximum": 10540.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10540.31, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8354.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7807.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 2", "code_information": [ { "code": "1912", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9237.71, "maximum": 12470.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12470.91, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9884.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9237.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 3", "code_information": [ { "code": "1913", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12200.69, "maximum": 16470.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16470.93, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13054.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12200.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE- SOI : 4", "code_information": [ { "code": "1914", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18727.73, "maximum": 25282.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25282.44, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20038.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18727.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 1", "code_information": [ { "code": "1921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8493.52, "maximum": 11466.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11466.25, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9088.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8493.52, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 2", "code_information": [ { "code": "1922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10796.06, "maximum": 14574.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14574.68, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11551.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10796.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 3", "code_information": [ { "code": "1923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15382.05, "maximum": 20765.77, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20765.77, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16458.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15382.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS - SOI : 4", "code_information": [ { "code": "1924", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25280.2, "maximum": 34128.27, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34128.27, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27049.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25280.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC", "code_information": [ { "code": "306", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15809, "minimum": 9545.7075, "maximum": 31619.38, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19762.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15869.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22484.21 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 31619.38, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15809.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20552.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22133.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15809.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19762.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28647.16, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 22228.42, "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": 23082.15, "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": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16654.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15809.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15809.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25295.5, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16026.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15809.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20366.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15712, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26870.27 } ] } ] }, { "description": "CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC", "code_information": [ { "code": "307", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9425, "minimum": 7345.1475, "maximum": 18850.86, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11781.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9462.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13790.74 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18850.86, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9425.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12253.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13195.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9425.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11781.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17078.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 13252.15, "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": 13761.13, "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": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9930.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9425.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9425.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15080.69, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9556.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9425.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10860 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9368.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16623.9 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC", "code_information": [ { "code": "275", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 69329, "minimum": 37350, "maximum": 138658.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 86661.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 69575.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102937.53 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 138658.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 69329.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 90127.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 97060.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 69329.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 86661.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 125624.4, "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": 97476.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 101220.54, "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": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 73020.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 69329.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 69329.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 110926.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 70264.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 69329.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 79793 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 68887.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 126814.63 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITH MCC", "code_information": [ { "code": "276", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 58501, "minimum": 27900, "maximum": 117002.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 73126.44, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 58709.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 90858.56 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 117002.3, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 58501.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 76051.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 81901.61, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 58501.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 73126.44, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 106004.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 82252.62, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 85411.68, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 61616.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 58501.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 58501.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 93601.84, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 59291.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 58501.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 46164 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 58128.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 111156.15 } ] } ] }, { "description": "CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC", "code_information": [ { "code": "277", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45126, "minimum": 14850, "maximum": 90253.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 56408.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 45288.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69969.08 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 90253.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45126.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 58664.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 63177.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 45126.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 56408.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 81769.38, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 63447.99, "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": 65884.82, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 47530.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 45126.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45126.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 72202.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 45737, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45126.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 65647.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 44840.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83476.58 } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 1", "code_information": [ { "code": "1771", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9740.2, "maximum": 13149.27, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13149.27, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10422.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9740.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 2", "code_information": [ { "code": "1772", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14638.92, "maximum": 19762.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19762.54, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15663.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14638.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 3", "code_information": [ { "code": "1773", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18511.47, "maximum": 24990.48, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24990.48, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19807.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18511.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT - SOI : 4", "code_information": [ { "code": "1774", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28401.14, "maximum": 38341.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38341.54, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30389.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28401.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "258", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30901, "minimum": 21600, "maximum": 61802.48, "payers_information": [ { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 30901.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 38626.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 55993.05, "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": 43447.14, "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": 45115.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32548.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 30901.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30901.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49441.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 31320.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30901.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38157.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 50343.63 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 38626.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 31013.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39628.27 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 61802.48, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 30901.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 40171.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 43261.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30706.4, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC", "code_information": [ { "code": "259", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20109, "minimum": 10800, "maximum": 42205.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 25137.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 20184.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27309.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 40219.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20109.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 26142.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 28153.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20109.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25137.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36439.07, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 28274.46, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29360.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21183.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 20109.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20109.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32175.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 20384.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20109.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23906 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19984.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31541.26 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC", "code_information": [ { "code": "261", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18841, "minimum": 13500, "maximum": 37683.74, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 23552.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 18911.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27531.74 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 37683.74, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18841.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 24494.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26378.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18841.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23552.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 34141.47, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 26491.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 27509.13, "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": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19848.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 18841.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18841.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30146.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19099.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18841.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33991.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18724.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34051.71 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC", "code_information": [ { "code": "260", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31967, "minimum": 24529.2375, "maximum": 72395.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 39959.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 32083.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 48503.16 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 63935.7, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31967.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 41558.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 44754.99, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 31967.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 39959.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57925.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 44946.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 46673.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33672.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 31967.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31967.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 51148.56, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 32401.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31967.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 72395.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 31766.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61122.96 } ] } ] }, { "description": "CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CCMCC", "code_information": [ { "code": "262", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16330, "minimum": 9000, "maximum": 39669.765, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20413.69, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16392.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24071.62 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 32661.9, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16330.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21230.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22863.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16330.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20413.69, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29591.68, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 22961.32, "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": 23843.19, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17203.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16330.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16330.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26129.52, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16554.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16330.95, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20644.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16229.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27236.34 } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 1", "code_information": [ { "code": "2001", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3867.24, "maximum": 5220.77, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5220.77, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4137.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3867.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 2", "code_information": [ { "code": "2002", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5660.93, "maximum": 7642.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7642.26, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6057.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5660.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 3", "code_information": [ { "code": "2003", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8622.85, "maximum": 11640.85, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11640.85, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9226.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8622.85, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC STRUCTURAL & VALVULAR DISORDERS - SOI : 4", "code_information": [ { "code": "2004", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15253.78, "maximum": 20592.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20592.6, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16321.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15253.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC", "code_information": [ { "code": "217", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 63980, "minimum": 23400, "maximum": 127961.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 79975.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 64208.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 93127.76 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 127961.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 83174.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 89572.94, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 79975.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 115932.97, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 89956.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 93411.78, "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": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 67387.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 102369.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 64844.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64355.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 115884.56 } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "216", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 94885, "minimum": 48150, "maximum": 189770.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 118606.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 95221.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 141993.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 189770.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 94885.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 123351.07, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 132839.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 94885.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 118606.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 171932.42, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 133408.93, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 138532.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 99935.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 94885.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 94885.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 151816.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 96164.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 94885.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 140635 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 94278.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 173185.32 } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CCMCC", "code_information": [ { "code": "218", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 63980, "minimum": 10350, "maximum": 127961.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 79975.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 64208.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 83345.78 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 127961.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 83174.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 89572.94, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 79975.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 115932.97, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 89956.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 93411.78, "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": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 67387.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 102369.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 64844.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 63980.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 80916.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 63573, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 106757.93 } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC", "code_information": [ { "code": "220", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52008, "minimum": 25200, "maximum": 104017.96, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 65011.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 52195.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76731.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 104017.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 52008.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 67611.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 72812.57, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 52008.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 65011.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 94240.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 73124.63, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 75933.11, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 54779, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 52008.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 52008.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 83214.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 52711.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 52008.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64225.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 51678.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 95047.27 } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "219", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 74608, "minimum": 38250, "maximum": 149216.5, "payers_information": [ { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 74873.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 112819 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 149216.5, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 74608.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 96990.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 104451.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 74608.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 93260.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 135190.15, "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": 104899.2, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 108928.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 78580.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 74608.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 74608.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 119373.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 75614.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 74608.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 93209 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 138846.5 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 93260.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 74132.2, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CCMCC", "code_information": [ { "code": "221", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 49189, "minimum": 13950, "maximum": 98379.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 61487.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 49365.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68011.52 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 98379.46, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 49189.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 63946.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 68865.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 49189.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 61487.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 89131.79, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 69160.76, "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": 71817.01, "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": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 51809.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 49189.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 49189.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 78703.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 49854.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 49189.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 53465.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 48877.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 82412.46 } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1621", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38042.75, "maximum": 51357.71, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51357.71, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40705.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38042.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1622", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 44276.14, "maximum": 59772.79, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 59772.79, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47375.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44276.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1623", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 57853.9, "maximum": 78102.77, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 78102.77, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 61903.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57853.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1624", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 80771.14, "maximum": 109041.04, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 109041.04, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 86425.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 80771.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 31937.63, "maximum": 43115.8, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43115.8, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34173.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31937.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 36891.48, "maximum": 49803.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49803.5, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39473.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36891.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 48537.74, "maximum": 65525.95, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65525.95, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 51935.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48537.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 71005.5, "maximum": 95857.43, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 95857.43, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 75975.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 71005.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 1", "code_information": [ { "code": "2051", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4035.8, "maximum": 5448.33, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5448.33, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4318.31, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4035.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 2", "code_information": [ { "code": "2052", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5360.93, "maximum": 7237.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7237.26, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5736.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5360.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 3", "code_information": [ { "code": "2053", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8170.19, "maximum": 11029.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11029.76, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8742.1, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8170.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CARDIOMYOPATHY - SOI : 4", "code_information": [ { "code": "2054", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15093.7, "maximum": 20376.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20376.5, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16150.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15093.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Care Of Miscarriage", "code_information": [ { "code": "59820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9781.33, "discounted_cash": 4143, "minimum": 241.91, "maximum": 9781.33, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8286.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 258.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3935.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.91 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 350.77 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 254.01 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH CC", "code_information": [ { "code": "035", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23659, "minimum": 8550, "maximum": 47318.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 29574.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 23746.31, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33642.92 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 47318.9, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 23659.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 30757.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 33123.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23659.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 29574.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 42870.92, "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": 33265.19, "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": 34542.8, "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": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24921.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 23659.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23659.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 37855.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 23981.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23659.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33685.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23511.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 40820.42 } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITH MCC", "code_information": [ { "code": "034", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 37921, "minimum": 21150, "maximum": 75842.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 47401.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 38058.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57079.58 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 75842.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 37921.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 49297.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 53089.97, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 37921.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 47401.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 68713.59, "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": 53317.5, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 55365.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 39942.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 37921.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 37921.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 60674.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 38435.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 37921.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52891 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 37681.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69781.24 } ] } ] }, { "description": "CAROTID ARTERY STENT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "036", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19345, "minimum": 5400, "maximum": 38691.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24182.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19417.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26454.94 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 38691.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19345.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 25149.53, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27084.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19345.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24182.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35054.57, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 27200.18, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28244.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20378.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19345.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19345.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 30953.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19609.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19345.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27578.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19225.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32894.28 } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 1", "code_information": [ { "code": "3831", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3744.27, "maximum": 5054.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5054.76, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4006.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3744.27, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 2", "code_information": [ { "code": "3832", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5117.1, "maximum": 6908.09, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6908.09, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5475.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5117.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 3", "code_information": [ { "code": "3833", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7731.31, "maximum": 10437.27, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10437.27, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8272.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7731.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS & OTHER SKIN INFECTIONS - SOI : 4", "code_information": [ { "code": "3834", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14332.55, "maximum": 19348.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19348.94, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15335.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14332.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CELLULITIS WITH MCC", "code_information": [ { "code": "602", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14321, "minimum": 11299.9275, "maximum": 28642.1, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17901.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14375.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21762.92 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 28642.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14321.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18617.37, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20049.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14321.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17901.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25949.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 20135.4, "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": 20908.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15086.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14321.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14321.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22913.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14517.56, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14321.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15551.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14232.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26364.24 } ] } ] }, { "description": "CELLULITIS WITHOUT MCC", "code_information": [ { "code": "603", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9017, "minimum": 6999.04, "maximum": 19100.4975, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11272.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9053.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12943.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18035.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9017.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11723.22, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12625, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9017.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11272.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16340.36, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 12679.11, "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": 13166.08, "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": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9501.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9017.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9017.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14428.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9143.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9017.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6999.04 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8963.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15805.62 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH CC", "code_information": [ { "code": "472", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 29012, "minimum": 11250, "maximum": 58025.48, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 36265.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 29118.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43239.09 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 58025.48, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 29012.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 37716.56, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 40617.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 29012.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 36265.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 52571.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 40791.91, "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": 42358.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30559.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 29012.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 29012.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 46420.38, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 29406.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 29012.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 33787 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 28830.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51989.15 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 47151, "minimum": 31950, "maximum": 94303.8, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 58939.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 47321.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71967.61 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 94303.8, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 47151.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 61297.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 66012.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 47151.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 58939.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 85439.24, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 66295.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 68841.77, "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": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49663.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 47151.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 47151.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 75443.04, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 47789.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 47151.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 53977.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 46852.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87162.4 } ] } ] }, { "description": "CERVICAL SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "473", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24148, "minimum": 7200, "maximum": 48297.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 30186.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 24237.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35999.9 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 48297.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24148.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 31393.6, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 33808.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24148.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30186.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 43757.84, "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": 33953.38, "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": 35257.42, "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": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25437.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 24148.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24148.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38638.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 24477.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24148.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28868.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 23997.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 42482.09 } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 1", "code_information": [ { "code": "5401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5389.76, "maximum": 7276.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7276.18, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5767.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5389.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 2", "code_information": [ { "code": "5402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6800.75, "maximum": 9181.01, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9181.01, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7276.8, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6800.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 3", "code_information": [ { "code": "5403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9359.2, "maximum": 12634.92, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12634.92, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10014.34, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9359.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN DELIVERY - SOI : 4", "code_information": [ { "code": "5404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21052.9, "maximum": 28421.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28421.42, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22526.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21052.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH CC", "code_information": [ { "code": "784", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10840, "minimum": 7540, "maximum": 21681.66, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10882.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14983.13 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 21681.66, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10840.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14093.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15177.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10840.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13551.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11421.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10840.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10840.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10990.6, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10840.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11253.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10775.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19434.02 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITH MCC", "code_information": [ { "code": "783", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24281, "minimum": 7540, "maximum": 48563.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 24371, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25922.39 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 48563.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24281.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 31566.44, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 33994.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24281.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30352.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25577.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 24281.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24281.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 24612.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24281.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17835.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24129.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33055.78 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "785", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9855, "minimum": 7540, "maximum": 19710.32, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9893.73, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12674.43 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19710.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9855.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12811.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13797.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9855.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12318.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10383.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9855.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9855.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9991.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9855.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9336.96 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9795.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15674.63 } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 1", "code_information": [ { "code": "5391", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5511.04, "maximum": 7439.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7439.9, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5896.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5511.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 2", "code_information": [ { "code": "5392", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6779.76, "maximum": 9152.68, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9152.68, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6779.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7254.34, "additional_payer_notes": "107% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 3", "code_information": [ { "code": "5393", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11858.17, "maximum": 16008.53, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16008.53, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12688.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11858.17, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITH STERILIZATION- SOI : 4", "code_information": [ { "code": "5394", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24337.19, "maximum": 32855.21, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32855.21, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26040.79, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24337.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITH CC", "code_information": [ { "code": "787", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11387, "minimum": 7540, "maximum": 22774.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11431.08, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15378.16 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 22774.3, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11387.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14803.3, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15942.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11387.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14233.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11996.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11387.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11387.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11544.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11387.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16657 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11317.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19053.6 } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITH MCC", "code_information": [ { "code": "786", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16519, "minimum": 7540, "maximum": 33039.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16581.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25596.12 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 33039.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16519.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21475.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23127.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16519.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20649.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17402.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16519.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16519.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16745.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16519.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16417.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28996.71 } ] } ] }, { "description": "CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CCMCC", "code_information": [ { "code": "788", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9864, "minimum": 7540, "maximum": 19729.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9000, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9903.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12509.11 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19729.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9864.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12824.23, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13810.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9864.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12330.99, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13628, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10393.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9864.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9864.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 7540, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10001.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9864.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12173.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9805.35, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16234.5 } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 1", "code_information": [ { "code": "6951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5846.45, "maximum": 7892.71, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7892.71, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6255.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5846.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 2", "code_information": [ { "code": "6952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8459.6, "maximum": 11420.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11420.46, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9051.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8459.6, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 3", "code_information": [ { "code": "6953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16628.73, "maximum": 22448.79, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22448.79, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17792.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16628.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY FOR ACUTE LEUKEMIA - SOI : 4", "code_information": [ { "code": "6954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39025.46, "maximum": 52684.37, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52684.37, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41757.24, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39025.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC", "code_information": [ { "code": "837", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46916, "minimum": 27084.015, "maximum": 93833.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 58646, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 47085.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 70870.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 93833.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 46916.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 60991.84, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 65683.52, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 46916.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 58646, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 85013.24, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 65965.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 68498.53, "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": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 49416.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 46916.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46916.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 75066.88, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 47551.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46916.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 62343.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 46618.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89852.3 } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT", "code_information": [ { "code": "838", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20739, "minimum": 18734.6025, "maximum": 41478.06, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 25923.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 20815.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29285.95 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 41478.06, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20739.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 26960.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29034.64, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20739.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25923.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37579.12, "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": 29159.08, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30278.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21846.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 20739.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20739.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33182.45, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 21021.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20739.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19052.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20609.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36395.28 } ] } ] }, { "description": "CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "839", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14538, "minimum": 12602.4, "maximum": 41972.8275, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 18173.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14593.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19065.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 29077.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14538.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18900.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20354.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14538.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18173.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26344.32, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 20441.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21226.66, "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": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15316.26, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14538.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14538.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23262.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14738.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14538.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12602.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14449.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24591.31 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC", "code_information": [ { "code": "847", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13231, "minimum": 11020.965, "maximum": 26462.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16539.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13281.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17740.99 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 26462.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13231.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 17200.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18523.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13231.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16539.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23975.15, "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": 18603.24, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19317.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13939.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13231.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13231.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21170.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13413.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13231.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11073.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13150.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22802.23 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC", "code_information": [ { "code": "846", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25605, "minimum": 16973.895, "maximum": 51211.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 32007.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 25699.45, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35757.03 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 51211.5, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 25605.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 33287.48, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 35848.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 25605.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 32007.19, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 46397.62, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 36001.68, "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": 37384.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26971.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 25605.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 25605.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 40969.2, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 25953.9, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 25605.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19107.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 25445, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45826.97 } ] } ] }, { "description": "CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "848", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8810, "minimum": 8758.04, "maximum": 35155.7625, "payers_information": [ { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8845.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12234.06 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17621.4, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8810.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11453.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12334.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8810.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11013.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15964.99, "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": 12387.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12863.62, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9283.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8810.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8810.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14097.12, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8933.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8810.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8930.15 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14694.85 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11013.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8758.04, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CHEST PAIN", "code_information": [ { "code": "313", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7563, "minimum": 7519.28, "maximum": 15127.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9454.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7594.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10586.66 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 15127.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7563.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9833.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10589.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7563.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9454.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13705.82, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10634.87, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11043.32, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7970.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7563.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7563.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12102.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7669.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7563.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8030.76 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7519.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12801.69 } ] } ] }, { "description": "CHEST PAIN - SOI : 1", "code_information": [ { "code": "2031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4004, "maximum": 5405.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5405.4, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4284.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4004, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 2", "code_information": [ { "code": "2032", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4785.29, "maximum": 6460.14, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6460.14, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5120.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4785.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 3", "code_information": [ { "code": "2033", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6017.13, "maximum": 8123.13, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8123.13, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6438.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6017.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHEST PAIN - SOI : 4", "code_information": [ { "code": "2034", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9476.23, "maximum": 12792.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12792.91, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10139.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9476.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES", "code_information": [ { "code": "018", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 416699, "minimum": 55350, "maximum": 833399.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 520874.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 418162.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 539028.49 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 833399.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 416699.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 541709.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 583379.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 416699.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 520874.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 755060.02, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 585879.9, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 608381.69, "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": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 438863.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 416699.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 416699.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 666719.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 422302.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 416699.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 445066 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 414022, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 676741.87 } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC", "code_information": [ { "code": "415", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20539, "minimum": 20250, "maximum": 41079.18, "payers_information": [ { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35496.25 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 25674.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 20615.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28907.02 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 41079.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20539.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 26701.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 28755.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20539.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25674.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37217.74, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 28878.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29987.8, "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": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21636.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 20539.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20539.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32863.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 20819.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20411.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20539.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27510.9 } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC", "code_information": [ { "code": "414", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34952, "minimum": 34200, "maximum": 69905.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 43691.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 35079.22, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51575.57 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 69905.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 34952.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 45438.67, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 48933.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 34952.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 43691.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 63334.51, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 49143.66, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 51031.12, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 36815.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 34952.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 34952.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 55924.51, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 35426.54, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 34952.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47655.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 34731.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 62874.36 } ] } ] }, { "description": "CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "416", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13762, "minimum": 12600, "maximum": 27839.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17202.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13814.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19593.22 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 27524.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13762.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 17890.87, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19267.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13762.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17202.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24937.12, "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": 19349.67, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20092.83, "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": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14498.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13762.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13762.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22019.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13951.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13762.21, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 27839.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13677.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24587.72 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH CC", "code_information": [ { "code": "412", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20884, "minimum": 19800, "maximum": 41769.04, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 26105.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 20961.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30228.15 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 41769.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20884.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 27149.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29238.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20884.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26105.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 37842.75, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 29363.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30491.4, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21999.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 20884.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20884.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33415.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 21169.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20884.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28992.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20754.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38250.75 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITH MCC", "code_information": [ { "code": "411", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32454, "minimum": 25650, "maximum": 64908.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 40568.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 32572.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44482.69 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 64908.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32454.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 42190.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 45436.19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 32454.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 40568.03, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 58807.41, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 45630.91, "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": 47383.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34184.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 32454.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32454.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 51927.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 32894.59, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32454.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 37217.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 32249.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49103.66 } ] } ] }, { "description": "CHOLECYSTECTOMY WITH C.D.E. WITHOUT CCMCC", "code_information": [ { "code": "413", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16625, "minimum": 12600, "maximum": 33251.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20782.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16688.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22086.26 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 33251.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16625.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21613.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23276.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16625.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20782.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30125.91, "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": 23375.85, "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": 24273.64, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17514.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16625.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16625.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26601.25, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16853.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16625.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22612.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16522.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29832.93 } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 1", "code_information": [ { "code": "2631", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9312.98, "maximum": 12572.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12572.52, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9964.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9312.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 2", "code_information": [ { "code": "2632", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11931.43, "maximum": 16107.43, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16107.43, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12766.63, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11931.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 3", "code_information": [ { "code": "2633", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16322.36, "maximum": 22035.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22035.19, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17464.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16322.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHOLECYSTECTOMY- SOI : 4", "code_information": [ { "code": "2634", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27036.79, "maximum": 36499.67, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36499.67, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28929.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27036.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 1", "code_information": [ { "code": "4701", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3852.4, "maximum": 5200.74, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5200.74, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4122.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3852.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 2", "code_information": [ { "code": "4702", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4928.4, "maximum": 6653.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6653.34, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5273.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 3", "code_information": [ { "code": "4703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8182.91, "maximum": 11046.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11046.93, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8755.71, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8182.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC KIDNEY DISEASE - SOI : 4", "code_information": [ { "code": "4704", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14561.53, "maximum": 19658.07, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19658.07, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15580.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14561.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 1", "code_information": [ { "code": "1401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4604.01, "maximum": 6215.41, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6215.41, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4926.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4604.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5528.42, "maximum": 7463.37, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7463.37, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5915.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5528.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7406.92, "maximum": 9999.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9999.34, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7925.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7406.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12433.91, "maximum": 16785.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16785.78, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13304.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12433.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC", "code_information": [ { "code": "191", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8749, "minimum": 8696.77, "maximum": 17498.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10936.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8783.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12421.33 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17498.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8749.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11373.75, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12248.66, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8749.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10936.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15853.26, "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": 12301.15, "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": 12773.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9218.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8749.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8749.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13998.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8870.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8749.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9844.24 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8696.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15416.22 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC", "code_information": [ { "code": "190", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11299, "minimum": 11064.7, "maximum": 22598.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14124.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11343.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16122.85 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 22598.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11299.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14689.31, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15819.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11299.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14124.34, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20474.64, "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": 15887.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16497.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11904.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11299.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11299.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18079.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11455.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11299.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11064.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11230.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20151.81 } ] } ] }, { "description": "CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CCMCC", "code_information": [ { "code": "192", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6812, "minimum": 6135.19, "maximum": 13624.74, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8515.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6840.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9389.88 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 13624.74, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6812.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8856.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9537.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6812.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8515.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12344.01, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 9578.19, "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": 9946.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7178.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6812.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6812.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10899.79, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6908.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6812.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6135.19 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6772.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11613.76 } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "286", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21947, "minimum": 13884.5475, "maximum": 43894.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 27434.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 22028.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31537.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 43894.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21947.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 28531.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30726.19, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21947.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27434.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39768.47, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 30857.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32043.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23118.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 21947.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21947.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35115.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 22246.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21947.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24977 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21810.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39716.83 } ] } ] }, { "description": "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "287", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10937, "minimum": 9450, "maximum": 35112.945, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 13671.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10979.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15824.39 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 21874.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10937.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14218.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15312.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10937.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13671.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19818.17, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 15377.68, "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": 15968.28, "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": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11523.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10937.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10937.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17499.49, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11088.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10937.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14852.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10870.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19554.25 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "433", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10803, "minimum": 10737.8, "maximum": 21606.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 13504.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10845.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15084.08 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 21606.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10803.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14044.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15124.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10803.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13504.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19575.51, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 15189.38, "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": 15772.76, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11382.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10803.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10803.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17285.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10952.56, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10803.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12367.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10737.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19197.15 } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "432", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19590, "minimum": 19468.5, "maximum": 39181.04, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 27544.27, "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": 28602.16, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20636.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19590.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19590.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31344.83, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19857.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19590.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24273.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35155.31 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24488.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19663.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28032.11 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 39181.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19590.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 25467.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27426.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19468.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19590.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24488.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35498.02, "additional_payer_notes": "181.20% of Medicare Rates" } ] } ] }, { "description": "CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "434", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7491, "minimum": 7447.48, "maximum": 14983.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9364.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7521.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9795.14 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14983.3, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7491.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9739.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10488.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7491.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9364.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13574.87, "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": 10533.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10937.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7894.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7491.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7491.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11986.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7596.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7491.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8145.95 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7447.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12498.43 } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 1", "code_information": [ { "code": "0951", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7198.08, "maximum": 9717.41, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9717.41, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7701.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7198.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 2", "code_information": [ { "code": "0952", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8045.1, "maximum": 10860.89, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10860.89, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8608.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 3", "code_information": [ { "code": "0953", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10607.36, "maximum": 14319.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14319.94, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11349.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10607.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CLEFT LIP & PALATE REPAIR - SOI : 4", "code_information": [ { "code": "0954", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19181.45, "maximum": 25894.96, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25894.96, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20524.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19181.45, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Cltx Sho Dslc W/Mnpj W/Anes", "code_information": [ { "code": "23655", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9887.3, "discounted_cash": 2058, "minimum": 210.41, "maximum": 9887.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2572.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 305.09 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 220.93 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "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": 210.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3087.02, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2078.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2629.78, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4116.02, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2881.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2572.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2893.56, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3004.69, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 225.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2181.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 210.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2099.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1955.11, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 210.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 210.41 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2058.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2711.12, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Cmbn Ant Pst Colprhy", "code_information": [ { "code": "57260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18844, "discounted_cash": 6402, "minimum": 872.17, "maximum": 18844, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1264.65 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 915.78 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9603.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6466.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8181.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12804.9, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8963.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8003.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 9001.84, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9347.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 933.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6786.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6530.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6082.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 872.17 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6402.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8434.27, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Cmplx rpr trunk 2.6-7.5 cm", "code_information": [ { "code": "13101", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3500, "discounted_cash": 945, "minimum": 185.84, "maximum": 3500, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 269.47 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.13 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 185.84 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1891.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 198.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1002.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 185.84 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 964.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 898.61, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.84 }, { "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.84 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 3500, "discounted_cash": 945, "minimum": 185.84, "maximum": 3500, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 269.47 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 195.13 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 185.84 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 955.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1208.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1891.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1324.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1182.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 198.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1002.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 185.84 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 964.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 898.61, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.84 }, { "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 185.84 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 945.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1246.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 1", "code_information": [ { "code": "6611", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6078.61, "maximum": 8206.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8206.12, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6504.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6078.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 2", "code_information": [ { "code": "6612", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7714.35, "maximum": 10414.37, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10414.37, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8254.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7714.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 3", "code_information": [ { "code": "6613", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11209.5, "maximum": 15132.83, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15132.83, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11994.17, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11209.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION & PLATELET DISORDERS - SOI : 4", "code_information": [ { "code": "6614", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19298.06, "maximum": 26052.38, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26052.38, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20648.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19298.06, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COAGULATION DISORDERS", "code_information": [ { "code": "813", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15323, "minimum": 15228.5, "maximum": 30646.22, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19153.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15380.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22823.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 30646.22, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15323.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 19920.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21452.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15323.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19153.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27765.48, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 21544.29, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22371.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16142.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15323.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15323.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24516.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 15533.07, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15323.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15330 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15228.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27778.27 } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 1", "code_information": [ { "code": "7741", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2749.9, "maximum": 3712.37, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3712.37, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2942.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2749.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 2", "code_information": [ { "code": "7742", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3481.37, "maximum": 4699.85, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3725.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4699.85, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3481.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 3", "code_information": [ { "code": "7743", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5959.88, "maximum": 8045.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8045.84, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6377.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5959.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "COCAINE ABUSE & DEPENDENCE - SOI : 4", "code_information": [ { "code": "7744", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15091.58, "maximum": 20373.63, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20373.63, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16147.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Colonoscopy And Biopsy", "code_information": [ { "code": "45380", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9591.67, "discounted_cash": 1531, "minimum": 473.68, "maximum": 9591.67, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 686.84 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 497.36 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Catalina Research Institute", "plan_name": "Catalina Research Institute", "methodology": "fee schedule", "standard_charge_dollar": 600 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3063.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2153.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2236.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 506.84 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1623.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1562.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1454.96, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 473.68 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Colonoscopy W/Band Ligation", "code_information": [ { "code": "45398", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10761.6, "discounted_cash": 1531, "minimum": 600.2535, "maximum": 10761.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 600.25 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3063.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1623.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1562.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1454.96, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional 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": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Colonoscopy W/Lesion Removal", "code_information": [ { "code": "45385", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10781.3, "discounted_cash": 1531, "minimum": 574.08, "maximum": 10781.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 832.42 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 602.78 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2297.31, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1546.86, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Catalina Research Institute", "plan_name": "Catalina Research Institute", "methodology": "fee schedule", "standard_charge_dollar": 600 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1957.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3063.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2144.16, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1914.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2153.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2236.05, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 614.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1623.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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 Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1562.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1454.96, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.08 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1531.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2017.57, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC", "code_information": [ { "code": "454", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 89484.75, "maximum": 89484.75, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89484.75 } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC", "code_information": [ { "code": "453", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 129647.04, "maximum": 129647.04, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 129647.04 } ] } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CCMCC", "code_information": [ { "code": "455", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 67382.4, "maximum": 67382.4, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 67382.4 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH CC", "code_information": [ { "code": "381", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11066, "minimum": 10999.1, "maximum": 22132.6, "payers_information": [ { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14386.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15492.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11066.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13832.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20052.14, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 15559.22, "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": 16156.8, "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": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11659.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11066.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11066.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17706.08, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11219.08, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11066.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12302.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19543.49 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 13832.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11109.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15698.57 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 22132.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11066.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10999.1, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITH MCC", "code_information": [ { "code": "380", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19532, "minimum": 18343.1, "maximum": 39065.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24415.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19605.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28507.6 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 39065.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19532.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 25392.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27345.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19532.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24415.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35393.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 27462.99, "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": 28517.76, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20575.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19532.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19532.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31252.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19799.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19532.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18343.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19411, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 34530.83 } ] } ] }, { "description": "COMPLICATED PEPTIC ULCER WITHOUT CCMCC", "code_information": [ { "code": "382", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8340, "minimum": 7264.93, "maximum": 16681.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10425.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8373.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11076.78 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16681.02, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8340.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10842.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11676.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8340.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10425.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15113, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 11726.76, "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": 12177.14, "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": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8788.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8340.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8340.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13344.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8456.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8340.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7264.93 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8290.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13445.9 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH CC", "code_information": [ { "code": "920", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10283, "minimum": 8931.99, "maximum": 20567.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 12854.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10324.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15125.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 20567.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10283.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 13369.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14397.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10283.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12854.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18634.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 14459.19, "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": 15014.52, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10835.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10283.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10283.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16454.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10426.24, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10283.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10119.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10221.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18229.94 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH MCC", "code_information": [ { "code": "919", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18266, "minimum": 13004.8425, "maximum": 36533.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 22833.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 18334.63, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26696.34 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 36533.3, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18266.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 23746.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25573.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18266.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 22833.31, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33099.17, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 25682.91, "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": 26669.31, "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": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19242.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 18266.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18266.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29226.64, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18516.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18266.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17471.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18153.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32723.81 } ] } ] }, { "description": "COMPLICATIONS OF TREATMENT WITHOUT CCMCC", "code_information": [ { "code": "921", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7259, "minimum": 7216.76, "maximum": 22698.465, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9074.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7288.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10209.19 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14518.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7259.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9437.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10163.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7259.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9074.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13154.11, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10206.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10598.78, "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": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7649.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7259.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7259.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11615.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7361.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7259.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7365.41 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7216.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12340.52 } ] } ] }, { "description": "CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES", "code_information": [ { "code": "212", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 105400, "minimum": 56250, "maximum": 210800.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 131750.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 105773.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 157581.13 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 210800.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 105400.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 137020.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 147560.41, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 105400.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 131750.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 190985.33, "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": 148192.81, "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": 153884.42, "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": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 111009.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 105400.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 105400.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 168640.46, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 106820.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 105400.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 148168 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 104726, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 195486.9 } ] } ] }, { "description": "CONCUSSION WITH CC", "code_information": [ { "code": "089", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11211, "minimum": 11143.7, "maximum": 22423.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14014.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11255.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16823.65 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 22423.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11211.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14575.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15696.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11211.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14014.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20315.76, "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": 15763.78, "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": 16369.21, "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": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11812.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11211.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11211.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17938.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11366.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11211.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18639.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11143.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19238.43 } ] } ] }, { "description": "CONCUSSION WITH MCC", "code_information": [ { "code": "088", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13651, "minimum": 13567.6, "maximum": 27302.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17064.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13703.28, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22440.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 27302.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13651.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 17746.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19111.97, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13651.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17064.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24736.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 19193.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19931.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14381.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13651.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13651.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21842.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13838.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13651.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19187.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13567.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25314.48 } ] } ] }, { "description": "CONCUSSION WITHOUT CCMCC", "code_information": [ { "code": "090", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8558, "minimum": 8507.23, "maximum": 17116.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10697.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8592.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13676.63 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17116.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8558.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11125.74, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11981.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8558.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10697.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15507.57, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 12032.91, "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": 12495.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9017.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8558.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8558.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13693.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8677.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8558.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15270 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8507.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15383.92 } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 1", "code_information": [ { "code": "0571", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4449.24, "maximum": 6006.47, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6006.47, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4760.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4449.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 2", "code_information": [ { "code": "0572", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6917.15, "maximum": 9338.15, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9338.15, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7401.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6917.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 3", "code_information": [ { "code": "0573", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9804.86, "maximum": 13236.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13236.56, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10491.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9804.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA - SOI : 4", "code_information": [ { "code": "0574", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16634.03, "maximum": 22455.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22455.94, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17798.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16634.03, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Conization Of Cervix", "code_information": [ { "code": "57522", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11944.9, "discounted_cash": 4143, "minimum": 321.98, "maximum": 11944.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 466.87 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.08 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8286.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3935.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.98 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 1", "code_information": [ { "code": "3461", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5540.08, "maximum": 7479.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7479.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5927.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5540.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 2", "code_information": [ { "code": "3462", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7614.7, "maximum": 10279.85, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10279.85, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8147.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7614.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 3", "code_information": [ { "code": "3463", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11432.12, "maximum": 15433.36, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15433.36, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12232.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11432.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS - SOI : 4", "code_information": [ { "code": "3464", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21898.49, "maximum": 29562.96, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29562.96, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23431.38, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21898.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH CC", "code_information": [ { "code": "546", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11739, "minimum": 10849.695, "maximum": 23479.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14674.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11784.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17546.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 23479.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15261.73, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16435.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14674.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21272.5, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 16506.14, "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": 17140.09, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12368.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18783.66, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11901.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11739.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15399.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11668.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20774.49 } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITH MCC", "code_information": [ { "code": "545", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24538, "minimum": 14965.365, "maximum": 49076.36, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 34500.68, "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": 35825.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25847.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 24538.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24538.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39261.09, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 24871.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24538.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29700.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 45344.26 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 30672.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 24628.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36476.86 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 49076.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24538.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 31899.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 34353.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24384.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24538.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30672.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44463.18, "additional_payer_notes": "181.20% of Medicare Rates" } ] } ] }, { "description": "CONNECTIVE TISSUE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "547", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8683, "minimum": 8631.68, "maximum": 25053.4275, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10854.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8718, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12045.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17367.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8683.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11288.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12156.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8683.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10854.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15734.54, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 12209.03, "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": 12677.94, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9149.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8683.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8683.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13893.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8804.31, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8683.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9901.83 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13390.28 } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 1", "code_information": [ { "code": "3841", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4735.47, "maximum": 6392.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.88, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5066.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4735.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 2", "code_information": [ { "code": "3842", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6140.1, "maximum": 8289.14, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8289.14, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6569.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6140.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 3", "code_information": [ { "code": "3843", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8929.22, "maximum": 12054.45, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12054.45, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9554.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8929.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE - SOI : 4", "code_information": [ { "code": "3844", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15409.61, "maximum": 20802.97, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20802.97, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16488.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15409.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Conz Of Cervix W/Scope Leep", "code_information": [ { "code": "57461", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11236.6, "discounted_cash": 4143, "minimum": 282.23, "maximum": 11236.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 409.23 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.34 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6214.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4184.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5294.15, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8286.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5800.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5178.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5825.17, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6048.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 301.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4391.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4225.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3935.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 282.23 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4143.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5457.89, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Cor Hlx Vlgs Double Osteot", "code_information": [ { "code": "28299", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18750, "discounted_cash": 9286, "minimum": 792.49, "maximum": 18750, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11608.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1149.11 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 832.11 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "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": 792.49 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13930.46, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9379.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11867.16, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18573.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13001.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 11608.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 13057.48, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13558.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 847.96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9844.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 792.49 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 9472.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8822.62, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 792.49 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 792.49 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9286.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12234.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Cor hlx vlgs dstl mtar osteo", "code_information": [ { "code": "28296", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13469.84, "discounted_cash": 4187, "minimum": 574.61, "maximum": 13469.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 833.18 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 603.34 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8375.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 614.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 574.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 13469.8, "discounted_cash": 4187, "minimum": 574.61, "maximum": 13469.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 833.18 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 603.34 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8375.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5887.92, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6114.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 614.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 574.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 574.61 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1651", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 35209.1, "maximum": 47532.29, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47532.29, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37673.74, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35209.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1652", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38566.44, "maximum": 52064.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52064.69, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41266.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38566.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1653", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 46931.69, "maximum": 63357.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63357.78, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 50216.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46931.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS W AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1654", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 63659, "maximum": 85939.65, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 85939.65, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 68115.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 63659, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC", "code_information": [ { "code": "233", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 74289, "minimum": 50850, "maximum": 148578.66, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 92861.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 74553.45, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 114112.34 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 148578.66, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 74289.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 96576.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 104005.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 74289.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 92861.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 134612.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 104450.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 108462.42, "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": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 78244.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 74289.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 74289.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 118862.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 75291.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 74289.33, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 96157.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 73815.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 140262.33 } ] } ] }, { "description": "CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC", "code_information": [ { "code": "234", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 53260, "minimum": 36450, "maximum": 106521.18, "payers_information": [ { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 106521.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 53260.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 69238.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 74564.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 53260.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 66575.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 96508.19, "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": 74884.39, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 77760.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56097.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 53260.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 53260.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 85216.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 53980.34, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 53260.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 78867.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 95468.97 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 66575.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 53451.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 52921.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76048.07 } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITH MCC", "code_information": [ { "code": "231", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 81850, "minimum": 48600, "maximum": 163700.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 102312.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 82140.67, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 118729.74 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 163700.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 81850.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 106405.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 114590.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 81850.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 102312.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 148312.27, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 115081.16, "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": 119501.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 86207.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 81850.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 81850.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 130960.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 82953.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 81850.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 72591.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 81327.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 152060.92 } ] } ] }, { "description": "CORONARY BYPASS WITH PTCA WITHOUT MCC", "code_information": [ { "code": "232", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 59040, "minimum": 34200, "maximum": 118081.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 73800.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 59251.45, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87031.21 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 118081.44, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 59040.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 76752.94, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 82657.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 59040.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 73800.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 106981.78, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 83011.25, "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": 86199.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 62184.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 59040.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 59040.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 94465.15, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 59838.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 59040.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 83085.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 58664.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 109618.3 } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC", "code_information": [ { "code": "235", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57171, "minimum": 36450, "maximum": 114343, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 71464.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 57375.78, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 86036.34 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 114343, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 57171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 74322.95, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 80040.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 57171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 71464.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 103594.76, "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": 80383.13, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 83470.39, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60216.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 57171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 91474.4, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 57943.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57171.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 74100.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 56807.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 105589.73 } ] } ] }, { "description": "CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC", "code_information": [ { "code": "236", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40986, "minimum": 26100, "maximum": 81972.72, "payers_information": [ { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 73790.07 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 51232.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 41133.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59124.93 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 81972.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 40986.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 53282.27, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 57380.9, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 40986.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 51232.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 74267.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 57626.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 59840.09, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 43170.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 40986.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40986.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 65578.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 41541.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40986.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 59888.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 40726.7, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 1", "code_information": [ { "code": "1661", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29768.67, "maximum": 40187.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40187.7, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31852.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29768.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 2", "code_information": [ { "code": "1662", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33063.46, "maximum": 44635.67, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44635.67, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35377.9, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33063.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 3", "code_information": [ { "code": "1663", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39961.53, "maximum": 53948.07, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53948.07, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42758.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39961.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY BYPASS WO AMI OR COMPLEX PDX - SOI : 4", "code_information": [ { "code": "1664", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 55046.75, "maximum": 74313.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74313.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58900.02, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55046.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC", "code_information": [ { "code": "323", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 42321, "minimum": 20700, "maximum": 84643.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 52902.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 42474.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 60570.42 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 84643.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 42321.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 55018.33, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 59250.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 42321.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 52902.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 76687.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 59504.44, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 61789.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 44576.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 42321.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 42321.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 67714.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 42894.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 42321.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 64807.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 42053.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 76433.31 } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC", "code_information": [ { "code": "324", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30986, "minimum": 10350, "maximum": 64711.515, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 38733.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 31099.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43432.21 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 61973.98, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 30986.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 40283.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 43381.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 30986.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 38733.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 56148.43, "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": 43567.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 45241.01, "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": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32639.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 30986.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30986.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 49579.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 31407.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30986.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 48851.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30791.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57334.86 } ] } ] }, { "description": "CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE", "code_information": [ { "code": "325", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31559, "minimum": 12150, "maximum": 63118.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 39449.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 31673.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38687.53 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 63118.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31559.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 41027.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 44183.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 31559.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 39449.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57185.49, "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": 44372.4, "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": 46076.61, "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": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33241.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 31559.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31559.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 50494.91, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 31987.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31559.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 38927.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 31360.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 51359.3 } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC", "code_information": [ { "code": "073", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16084, "minimum": 15984.8, "maximum": 32168.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20105.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16144.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22136 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 32168.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16084.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20909.58, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22518.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16084.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20105.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29144.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 22614.51, "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": 23483.06, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16943.89, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16084.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16084.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25734.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16304.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16084.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18438.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15984.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27735.2 } ] } ] }, { "description": "CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "074", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10558, "minimum": 10494.6, "maximum": 21117.04, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 13198.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10599.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15013.86 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 21117.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10558.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 13726.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14781.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10558.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13198.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19132.04, "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": 14845.28, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15415.44, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11124.28, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10558.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10558.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16893.63, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10704.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10558.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11481.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10494.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18705.47 } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "026", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 30584, "minimum": 13500, "maximum": 61168.48, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 38230.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 30695.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43205.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 61168.48, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 30584.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 39759.51, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 42817.94, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 30584.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 38230.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 55418.64, "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": 43001.44, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 44652.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32214.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 30584.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 30584.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 48934.78, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 30999.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 30584.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34801.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 30391.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 54885.41 } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "025", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 44434, "minimum": 29250, "maximum": 88869.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 55543.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 44594.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 64608.45 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 88869.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 44434.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 57765.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 62208.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 44434.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 55543.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 80515.82, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 62475.3, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 64874.78, "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": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46802.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 44434.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 44434.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 71095.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 45035.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 44434.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 52350.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 44152.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 80253.72 } ] } ] }, { "description": "CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "027", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24935, "minimum": 7200, "maximum": 49870.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 31168.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 25026.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35594.63 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 49870.3, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24935.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 32415.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 34909.21, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24935.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 31168.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 45182.49, "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": 35058.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 36405.32, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 26265.42, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 24935.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24935.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 39896.24, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 25274.27, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24935.15, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 34744 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24778.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44283.73 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA", "code_information": [ { "code": "955", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 65481, "minimum": 39600, "maximum": 130963.66, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 81852.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 65715.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 89102.9 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 130963.66, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 65481.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 85126.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 91674.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 65481.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 81852.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 118653.08, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 92067.45, "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": 95603.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 68968.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 65481.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 65481.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 104770.93, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 66365.79, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 65481.83, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 122654 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 65064.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 122531.25 } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22594.97, "maximum": 30503.21, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30503.21, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24176.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 2", "code_information": [ { "code": "9102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22650.1, "maximum": 30577.63, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30577.63, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24235.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22650.1, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33747.22, "maximum": 45558.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45558.75, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36109.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33747.22, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA - SOI : 4", "code_information": [ { "code": "9104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 56988.86, "maximum": 76934.96, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 76934.96, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60978.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 56988.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR", "code_information": [ { "code": "023", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 55838, "minimum": 32850, "maximum": 111677.92, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 69798.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 56038.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 82937.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 111677.92, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 55838.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 72590.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 78174.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 55838.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 69798.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 101180.2, "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": 78509.58, "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": 81524.88, "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": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 58812.72, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 55838.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 55838.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 89342.34, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 56593.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 55838.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 77556.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 55483.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 102375.85 } ] } ] }, { "description": "CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC", "code_information": [ { "code": "024", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 38318, "minimum": 17550, "maximum": 76636.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 47897.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 38456.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 55432.18 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 76636.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38318.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 49813.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 53645.73, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 38318.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 47897.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 69432.9, "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": 53875.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 55944.83, "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": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40360.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 38318.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 38318.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 61309.41, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 38837.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 38318.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 47765.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 38075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 68220.06 } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 1", "code_information": [ { "code": "0451", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6539.76, "maximum": 8828.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8828.68, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6997.54, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6539.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 2", "code_information": [ { "code": "0452", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8072.66, "maximum": 10898.09, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10898.09, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8637.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8072.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 3", "code_information": [ { "code": "0453", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10803.48, "maximum": 14584.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14584.7, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11559.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10803.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CVA & PRECEREBRAL OCCLUSION W INFARCT - SOI : 4", "code_information": [ { "code": "0454", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16939.34, "maximum": 22868.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22868.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18125.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16939.34, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 1", "code_information": [ { "code": "1311", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7099.49, "maximum": 9584.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9584.31, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7596.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7099.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 2", "code_information": [ { "code": "1312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12532.5, "maximum": 16918.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16918.88, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13409.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12532.5, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 3", "code_information": [ { "code": "1313", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17564.8, "maximum": 23712.48, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23712.48, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17564.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18794.34, "additional_payer_notes": "107% of State Medicaid Rates" } ] } ] }, { "description": "CYSTIC FIBROSIS - PULMONARY DISEASE - SOI : 4", "code_information": [ { "code": "1314", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18877.2, "maximum": 25484.22, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25484.22, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20198.6, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18877.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "CYSTOSCOPY AND TREATMENT", "code_information": [ { "code": "52332", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 4511, "minimum": 789.82, "maximum": 10500, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1145.24 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 829.31 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9022.98, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6586.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 845.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 4511, "minimum": 789.82, "maximum": 10500, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1145.24 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 829.31 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6767.24, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4556.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5764.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9022.98, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6316.09, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5639.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6343.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6586.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 845.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4782.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4601.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4285.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.82 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4511.49, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5943.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CCMCC", "code_information": [ { "code": "744", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 20370, "minimum": 14759.0625, "maximum": 40740.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 25462.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 20445.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27540.52 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 40740.02, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 20370.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 26481.01, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 28518.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 20370.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 25462.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 36910.46, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 28640.23, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 29740.21, "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": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21457.58, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 20370.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 20370.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 32592.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 20647.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 20370.01, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18678.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20243, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35063.79 } ] } ] }, { "description": "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CCMCC", "code_information": [ { "code": "745", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11586, "minimum": 5330.15, "maximum": 23173.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14483.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11631.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15155.77 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 23173.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11586.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15062.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16221.23, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11586.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14483.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20994.9, "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": 16290.75, "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": 16916.42, "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": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12207.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11586.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11586.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 18538.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11746.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11586.59, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5330.15 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11516.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18389.65 } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITH CCMCC", "code_information": [ { "code": "294", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8226.15, "maximum": 22035.9934, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16001.42 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16702.4 }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22035.99 } ] } ] }, { "description": "DEEP VEIN THROMBOPHLEBITIS WITHOUT CCMCC", "code_information": [ { "code": "295", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5904.9225, "maximum": 14172.6609, "payers_information": [ { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11662 }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10742.4 }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14172.66 } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 1", "code_information": [ { "code": "1791", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28107.49, "maximum": 37945.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37945.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30075.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28107.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 2", "code_information": [ { "code": "1792", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33373.01, "maximum": 45053.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 45053.56, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35709.12, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33373.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 3", "code_information": [ { "code": "1793", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 40597.59, "maximum": 54806.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54806.75, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43439.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 40597.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEFIBRILLATOR IMPLANTS- SOI : 4", "code_information": [ { "code": "1794", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54992.69, "maximum": 74240.13, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74240.13, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58842.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54992.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 1", "code_information": [ { "code": "0421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5906.88, "maximum": 7974.29, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7974.29, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6320.36, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5906.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 2", "code_information": [ { "code": "0422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7420.7, "maximum": 10017.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10017.94, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7940.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7420.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 3", "code_information": [ { "code": "0423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10008.4, "maximum": 13511.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13511.34, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10708.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10008.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS - SOI : 4", "code_information": [ { "code": "0424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18420.3, "maximum": 24867.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24867.4, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19709.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18420.3, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC", "code_information": [ { "code": "056", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23010, "minimum": 22866, "maximum": 46020.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 28762.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 23094.66, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 35025.51 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 46020.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 23010.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 29913.05, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 32214.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 23010.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 28762.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 41694.19, "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": 32352.12, "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": 33594.66, "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": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24237.96, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 23010.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 23010.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 36816.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 23323.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 23010.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29647.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 22866, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44935.12 } ] } ] }, { "description": "DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC", "code_information": [ { "code": "057", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13109, "minimum": 13029.6, "maximum": 26219.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16387.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13159.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19944.35 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 26219.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13109.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 17042.88, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18353.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13109.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16387.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23755.16, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 18432.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19140.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13811.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13109.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13109.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20975.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13290.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13109.91, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19798.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13029.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23945.3 } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH CC", "code_information": [ { "code": "158", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9392, "minimum": 9336.26, "maximum": 32748.9, "payers_information": [ { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15028.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9522.99, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10056.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16878.71 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11740.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9429.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13730.76 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18785.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12210.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13149.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11740.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17019.52, "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": 13206.09, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13713.3, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9896.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9392.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9336.26, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITH MCC", "code_information": [ { "code": "157", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17168, "minimum": 17061.8, "maximum": 58151.355, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 21460.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 17232.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24974.33 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 34336.48, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17168.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 22318.71, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 24035.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17168.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21460.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31108.85, "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": 24138.55, "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": 25065.63, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18085.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 17168.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17168.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27469.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 17403.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17168.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19804.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17061.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29384.32 } ] } ] }, { "description": "DENTAL AND ORAL DISEASES WITHOUT CCMCC", "code_information": [ { "code": "159", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7453, "minimum": 7141.18, "maximum": 24836.745, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9316.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7483.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9878.54 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14906.22, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7453.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9689.04, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10434.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7453.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9316.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13505.04, "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": 10479.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10881.54, "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": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7853.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7453.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7453.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11924.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7557.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7453.11, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7141.18 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7409.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11836.27 } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 1", "code_information": [ { "code": "1141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3289.49, "maximum": 4440.81, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4440.81, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3519.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3289.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 2", "code_information": [ { "code": "1142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4606.13, "maximum": 6218.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6218.28, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4928.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4606.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 3", "code_information": [ { "code": "1143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6926.69, "maximum": 9351.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9351.03, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7411.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6926.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DENTAL DISEASES AND DISORDERS - SOI : 4", "code_information": [ { "code": "1144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15815.63, "maximum": 21351.1, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21351.1, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16922.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15815.63, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DEPRESSIVE NEUROSES", "code_information": [ { "code": "881", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9692, "minimum": 5621.78, "maximum": 19384.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 12115.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9730.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13262.58 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19384.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9692.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12600.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13569.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9692.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12115.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17562.48, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 13627.4, "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": 14150.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10212.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9692.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9692.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15507.71, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9826.67, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9692.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5621.78 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9633.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16403.18 } ] } ] }, { "description": "Destruction Anal Lesion(S)", "code_information": [ { "code": "46924", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11935.6, "discounted_cash": 3552, "minimum": 338.58, "maximum": 11935.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 490.94 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 355.51 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.58 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5328.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3587.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7104.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 4994.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.58 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3623.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3374.85, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 338.58 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIABETES - SOI : 1", "code_information": [ { "code": "4201", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4059.12, "maximum": 5479.81, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5479.81, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4343.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4059.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 2", "code_information": [ { "code": "4202", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5392.73, "maximum": 7280.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7280.19, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5770.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5392.73, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 3", "code_information": [ { "code": "4203", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7786.43, "maximum": 10511.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10511.68, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8331.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7786.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES - SOI : 4", "code_information": [ { "code": "4204", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14323.01, "maximum": 19336.06, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19336.06, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15325.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14323.01, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIABETES WITH CC", "code_information": [ { "code": "638", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9261, "minimum": 7759.96, "maximum": 18523.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11577.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9298.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13158.71 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18523.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9261.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12040.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12966.28, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9261.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11577.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16782.07, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 13021.85, "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": 13521.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9758.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9261.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9261.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14818.61, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9390.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9261.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7759.96 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9206.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16458.81 } ] } ] }, { "description": "DIABETES WITH MCC", "code_information": [ { "code": "637", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14469, "minimum": 11628.195, "maximum": 28938.86, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 18086.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14524.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21204.04 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 28938.86, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14469.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18810.26, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20257.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14469.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18086.79, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26218.61, "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": 20344.02, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 21125.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15243.22, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14469.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14469.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23151.09, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14668.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14469.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 13103.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14380.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26132.75 } ] } ] }, { "description": "DIABETES WITHOUT CCMCC", "code_information": [ { "code": "639", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6611, "minimum": 5619.32, "maximum": 17329.41, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8264.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6639.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9107.51 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 13223.92, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6611.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8595.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9256.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6611.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8264.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11980.87, "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": 9296.42, "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": 9653.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6967.86, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6611.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6611.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10579.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6704.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6611.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5619.32 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6573.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11244.1 } ] } ] }, { "description": "Diagnostic Colonoscopy", "code_information": [ { "code": "45378", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9928.6, "discounted_cash": 1190, "minimum": 423.48, "maximum": 9928.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1487.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 614.05 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 444.65 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Catalina Research Institute", "plan_name": "Catalina Research Institute", "methodology": "fee schedule", "standard_charge_dollar": 600 }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2380.44, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1666.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1487.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 1673.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1737.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 453.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1261.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1214.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1130.71, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 423.48 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 1", "code_information": [ { "code": "2401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5584.61, "maximum": 7539.22, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7539.22, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5975.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5584.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 2", "code_information": [ { "code": "2402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7210.8, "maximum": 9734.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9734.58, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7715.56, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7210.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 3", "code_information": [ { "code": "2403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10169.54, "maximum": 13728.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13728.88, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10881.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10169.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY - SOI : 4", "code_information": [ { "code": "2404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15872.88, "maximum": 21428.39, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21428.39, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16983.98, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15872.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH CC", "code_information": [ { "code": "375", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12281, "minimum": 12206.3, "maximum": 24562.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 15351.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12328.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17531.77 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 24562.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12281.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15965.68, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17193.81, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12281.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 15351.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 22253.7, "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": 17267.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 17930.68, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12938.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12281.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12281.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19650.06, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12450.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12281.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14061.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12206.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22048.55 } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITH MCC", "code_information": [ { "code": "374", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21233, "minimum": 21100.7, "maximum": 42466.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 26541.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 21311.71, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30709.5 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 42466.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21233.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 27603.32, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29726.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21233.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26541.65, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38474.78, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 29854.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 31000.65, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22366.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 21233.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21233.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33973.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 21522.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21233.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 26623.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21100.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 37888.27 } ] } ] }, { "description": "DIGESTIVE MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "376", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9532, "minimum": 9475.07, "maximum": 19064.76, "payers_information": [ { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9664.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9532.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10884.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15845.1 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11915.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9569.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13041.66 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19064.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9532.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12392.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13345.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9532.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11915.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17272.67, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 13402.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13917.27, "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": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10043.57, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9532.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9532.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9475.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15251.81, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 1", "code_information": [ { "code": "5171", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6167.66, "maximum": 8326.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8326.34, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6599.4, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6167.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 2", "code_information": [ { "code": "5172", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8522.14, "maximum": 11504.89, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11504.89, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9118.69, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8522.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 3", "code_information": [ { "code": "5173", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12821.91, "maximum": 17309.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17309.58, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13719.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12821.91, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES - SOI : 4", "code_information": [ { "code": "5174", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21946.19, "maximum": 29627.36, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29627.36, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23482.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21946.19, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 1", "code_information": [ { "code": "2841", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5267.64, "maximum": 7111.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7111.31, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5636.37, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5267.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 2", "code_information": [ { "code": "2842", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7392.08, "maximum": 9979.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9979.31, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7909.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7392.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 3", "code_information": [ { "code": "2843", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9985.08, "maximum": 13479.86, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13479.86, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10684.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9985.08, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF GALLBLADDER & BILIARY TRACT - SOI : 4", "code_information": [ { "code": "2844", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17059.13, "maximum": 23029.83, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23029.83, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18253.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17059.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC", "code_information": [ { "code": "442", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9927, "minimum": 9867.57, "maximum": 19854.84, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 12409.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9966.25, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13920.96 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 19854.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9927.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12905.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 13898.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9927.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12409.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 17988.49, "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": 13957.95, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14494.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10459.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9927.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9927.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 15883.87, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10064.92, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9927.42, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11427.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9867.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17338.09 } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC", "code_information": [ { "code": "441", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17918, "minimum": 17807.5, "maximum": 35837.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 22398.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 17985.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26747.55 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 35837.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17918.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 23294.47, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25086.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17918.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 22398.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32468.9, "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": 25193.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26161.48, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18875.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 17918.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17918.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28670.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18163.65, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17918.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22160 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17807.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33922.51 } ] } ] }, { "description": "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CCMCC", "code_information": [ { "code": "443", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7368, "minimum": 7324.94, "maximum": 14736.64, "payers_information": [ { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7471.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7368.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7359.28 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12609.68 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9210.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7398.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10456.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 14736.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7368.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 9578.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10315.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7368.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9210.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13351.4, "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": 10359.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 10757.75, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7764.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7368.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7368.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7324.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 11789.31, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 1", "code_information": [ { "code": "2821", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4490.58, "maximum": 6062.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6062.28, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4804.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4490.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 2", "code_information": [ { "code": "2822", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5998.05, "maximum": 8097.37, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.37, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6417.91, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5998.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 3", "code_information": [ { "code": "2823", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9386.13, "maximum": 12671.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12671.28, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10043.16, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9386.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY - SOI : 4", "code_information": [ { "code": "2824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 20005.15, "maximum": 27006.95, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27006.95, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21405.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20005.15, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC", "code_information": [ { "code": "439", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8731, "minimum": 8679.54, "maximum": 17463.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10914.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8766.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12512.04 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17463.4, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8731.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11351.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12224.38, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8731.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10914.63, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15821.84, "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": 12276.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12748.28, "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": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9200.31, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8731.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8731.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13970.72, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8853.13, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8731.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9338.18 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8679.54, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15435.96 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC", "code_information": [ { "code": "438", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16333, "minimum": 16232.8, "maximum": 32667.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20417.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16395.13, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24415.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 32667.68, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16333.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21233.99, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22867.38, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16333.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20417.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29596.92, "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": 22965.38, "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": 23847.41, "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": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17206.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16333.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16333.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26134.14, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16557.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16333.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20004.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16232.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29854.46 } ] } ] }, { "description": "DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "440", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6613, "minimum": 6575.36, "maximum": 13227.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8267.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6641.11, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9006.56 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 13227.78, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6613.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8598.06, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9259.45, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6613.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8267.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 11984.37, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 9299.13, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9656.28, "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": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6969.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6613.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6613.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10582.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6706.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6613.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7018.65 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6575.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11037.74 } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 1", "code_information": [ { "code": "7521", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2817.75, "maximum": 3803.96, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3803.96, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3014.99, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2817.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 2", "code_information": [ { "code": "7522", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3671.13, "maximum": 4956.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4956.03, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3928.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3671.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 3", "code_information": [ { "code": "7523", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7618.94, "maximum": 10285.57, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10285.57, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8152.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7618.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY & IMPULSE CONTROL - SOI : 4", "code_information": [ { "code": "7524", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 33313.64, "maximum": 44973.41, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44973.41, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35645.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33313.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DISORDERS OF PERSONALITY AND IMPULSE CONTROL", "code_information": [ { "code": "883", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19572, "minimum": 12296, "maximum": 39144.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24465.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19644.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27438.11 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 39144.44, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19572.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 25443.89, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27401.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19572.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24465.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35464.86, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 27518.54, "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": 28575.44, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20617.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19572.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19572.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31315.55, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19839.31, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19572.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15021.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19450.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 33267.53 } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH CC", "code_information": [ { "code": "445", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11171, "minimum": 10764.5, "maximum": 22342.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 13964.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11214.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15900.47 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 22342.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11171.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 14522.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 15639.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11171.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13964.15, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 20242.43, "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": 15706.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 16310.13, "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": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11769.71, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11171.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11171.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 17874.11, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 11325.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11171.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10764.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11103.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19460.94 } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITH MCC", "code_information": [ { "code": "444", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16725, "minimum": 16408.3, "maximum": 33451.98, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20907.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16788.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23894.59 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 33451.98, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16725.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21743.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23416.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16725.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20907.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 30307.49, "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": 23516.74, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 24419.95, "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": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17619.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16725.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16725.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26761.58, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16954.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16725.99, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 16408.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16622.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30225.92 } ] } ] }, { "description": "DISORDERS OF THE BILIARY TRACT WITHOUT CCMCC", "code_information": [ { "code": "446", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8597, "minimum": 8207.21, "maximum": 17195.54, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10747.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8631.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11726.38 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 17195.54, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8597.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11177.1, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12036.88, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8597.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10747.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15579.16, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 12088.46, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12552.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9059.27, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8597.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8597.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13756.43, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8717.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8597.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8207.21 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8546.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14307.25 } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 1", "code_information": [ { "code": "2441", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4359.13, "maximum": 5884.83, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5884.83, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4664.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4359.13, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 2", "code_information": [ { "code": "2442", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5831.61, "maximum": 7872.67, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7872.67, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6239.82, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5831.61, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 3", "code_information": [ { "code": "2443", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8730.98, "maximum": 11786.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11786.82, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9342.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8730.98, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DIVERTICULITIS & DIVERTICULOSIS - SOI : 4", "code_information": [ { "code": "2444", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15668.28, "maximum": 21152.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21152.18, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16765.06, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15668.28, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 1", "code_information": [ { "code": "3041", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21066.31, "maximum": 28439.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28439.52, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22540.95, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21066.31, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 2", "code_information": [ { "code": "3042", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28158.38, "maximum": 38013.81, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38013.81, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30129.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28158.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 3", "code_information": [ { "code": "3043", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38877.05, "maximum": 52484.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52484.02, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 41598.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38877.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK - SOI : 4", "code_information": [ { "code": "3044", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54426.59, "maximum": 73475.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 73475.9, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58236.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54426.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 1", "code_information": [ { "code": "3031", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 32600.2, "maximum": 44010.27, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44010.27, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34882.21, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32600.2, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 2", "code_information": [ { "code": "3032", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 36947.67, "maximum": 49879.35, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49879.35, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39534.01, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36947.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 3", "code_information": [ { "code": "3033", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 49432.46, "maximum": 66733.82, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66733.82, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52892.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 49432.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK - SOI : 4", "code_information": [ { "code": "3034", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 74045.86, "maximum": 99961.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 99961.91, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 79229.07, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 74045.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 1", "code_information": [ { "code": "7701", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 2155.18, "maximum": 2909.49, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2909.49, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2306.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 2155.18, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 2", "code_information": [ { "code": "7702", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3378.54, "maximum": 4561.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4561.03, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3615.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3378.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 3", "code_information": [ { "code": "7703", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5481.78, "maximum": 7400.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7400.4, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5865.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5481.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE - SOI : 4", "code_information": [ { "code": "7704", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10998.54, "maximum": 14848.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14848.03, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11768.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10998.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "DYSEQUILIBRIUM", "code_information": [ { "code": "149", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7868, "minimum": 7821.79, "maximum": 15736.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9835.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7900.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 10895.36 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 15736.78, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7868.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10228.91, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11015.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7868.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9835.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14257.52, "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": 11062.96, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11487.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8291.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7868.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7868.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12589.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7978.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7868.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9410.48 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7821.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13413.6 } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC", "code_information": [ { "code": "147", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12877, "minimum": 12798.9, "maximum": 25755.42, "payers_information": [ { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13054.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12877.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 14903.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22337.46 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16097.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12926.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18080.42 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 25755.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12877.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 16741.02, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18028.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12877.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16097.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23334.41, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 18106.06, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18801.46, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13566.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12877.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12877.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12798.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20604.34, "additional_payer_notes": "160.00% of Medicare Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC", "code_information": [ { "code": "146", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21028, "minimum": 9752.01, "maximum": 42056.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 26285.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 21105.77, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30885.06 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 42056.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21028.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 27336.52, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 29439.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21028.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 26285.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 38102.9, "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": 29565.49, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 30701.01, "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": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 22150.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 21028.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21028.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 33644.94, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 21314.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21028.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17465.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 20896.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 41166.75 } ] } ] }, { "description": "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CCMCC", "code_information": [ { "code": "148", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8306, "minimum": 8257.37, "maximum": 16613.58, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10383.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8339.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13016.79 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16613.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8306.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10798.83, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11629.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8306.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10383.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15051.9, "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": 11679.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12127.91, "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": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8752.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8306.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8306.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13290.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8422.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8306.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10890.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8257.37, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14368.26 } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 1", "code_information": [ { "code": "1101", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6412.54, "maximum": 8656.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8656.93, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6861.42, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6412.54, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 2", "code_information": [ { "code": "1102", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6936.23, "maximum": 9363.91, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9363.91, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7421.77, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6936.23, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 3", "code_information": [ { "code": "1103", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10282.97, "maximum": 13882.01, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13882.01, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11002.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10282.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EAR, NOSE, MOUTH, THROAT, CRANIALFACIAL MALIGNANCIES - SOI : 4", "code_information": [ { "code": "1104", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17487.41, "maximum": 23608, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23608, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18711.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17487.41, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 1", "code_information": [ { "code": "7591", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6174.02, "maximum": 8334.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8334.93, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6606.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6174.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 2", "code_information": [ { "code": "7592", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8406.59, "maximum": 11348.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11348.9, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8995.05, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8406.59, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 3", "code_information": [ { "code": "7593", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13046.65, "maximum": 17612.98, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17612.98, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13959.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13046.65, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EATING DISORDERS - SOI : 4", "code_information": [ { "code": "7594", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 23951.9, "maximum": 32335.07, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 32335.07, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25628.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 23951.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES", "code_information": [ { "code": "003", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 205134, "minimum": 108450, "maximum": 410269.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 256418.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 205857.19, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 311927.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 410269.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 205134.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 266675.24, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 287188.72, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 205134.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 256418.5, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 371704.26, "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": 288419.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 299496.81, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 216048.14, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 205134.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 205134.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 328215.68, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 207895.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 205134.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 316800 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 203819, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 384581.92 } ] } ] }, { "description": "Egd Biopsy Single/Multiple", "code_information": [ { "code": "43239", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10818.7, "discounted_cash": 1160, "minimum": 335.91, "maximum": 10818.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 487.07 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 352.71 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2321.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 1632.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1694.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 359.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 335.91 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 335.91 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Egd Diagnostic Brush Wash", "code_information": [ { "code": "43235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10178.7, "discounted_cash": 1160, "minimum": 321.48, "maximum": 10178.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 466.15 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 337.55 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2321.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 1632.1, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1694.78, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 343.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 321.48 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 321.48 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Egd Varices Ligation", "code_information": [ { "code": "43244", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10323.5, "discounted_cash": 2455, "minimum": 308.14, "maximum": 12096.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 446.8 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 323.55 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 308.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3683.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2480.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3138.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4911.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3438.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 3453.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3585.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.71 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2603.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 308.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2505.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2333.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 308.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 308.14 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3241", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12305.64, "maximum": 16612.61, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16612.61, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13167.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12305.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3242", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13814.16, "maximum": 18649.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18649.12, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14781.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13814.16, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3243", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 19651.07, "maximum": 26528.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26528.94, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21026.64, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19651.07, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE HIP JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3244", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29312.83, "maximum": 39572.32, "payers_information": [ { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39572.32, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31364.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29312.83, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 1", "code_information": [ { "code": "3261", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12205.99, "maximum": 16478.09, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16478.09, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13060.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12205.99, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 2", "code_information": [ { "code": "3262", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12960.78, "maximum": 17497.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17497.05, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13868.03, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12960.78, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 3", "code_information": [ { "code": "3263", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18607.94, "maximum": 25120.72, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25120.72, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19910.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18607.94, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "ELECTIVE KNEE JOINT REPLACEMENT- SOI : 4", "code_information": [ { "code": "3264", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25927.93, "maximum": 35002.71, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35002.71, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27742.89, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25927.93, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "Endo Cholangiopancreatograph", "code_information": [ { "code": "43261", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12366.4, "discounted_cash": 4934, "minimum": 489.17, "maximum": 12366.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 709.3 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 513.63 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7401.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4983.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6305.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9868.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6908.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6937.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7204.34, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 523.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5230.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 5033.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4687.76, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 489.17 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH CC", "code_information": [ { "code": "644", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10502, "minimum": 9968.6925, "maximum": 21005.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 13128.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10543.49, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15533.24 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 21005.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10502.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 13653.43, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14703.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10502.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13128.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 19030.78, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 14766.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15333.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11065.45, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10502.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10502.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16804.22, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10647.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10502.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10058.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10439.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18543.97 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITH MCC", "code_information": [ { "code": "643", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16487, "minimum": 13299.375, "maximum": 32974.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20608.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16548.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24068.7 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 32974.08, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16487.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21433.15, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23081.86, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16487.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20608.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29874.52, "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": 23180.78, "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": 24071.08, "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": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17368.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16487.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16487.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26379.26, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16712.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16487.04, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18166.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16385, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29739.62 } ] } ] }, { "description": "ENDOCRINE DISORDERS WITHOUT CCMCC", "code_information": [ { "code": "645", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8029, "minimum": 6310.41, "maximum": 61000.665, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 11289.18, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11722.76, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8460.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8029.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8029.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12846.86, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8141.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8029.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6310.41 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13973.48 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10036.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8061.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11132.38 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16058.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8029.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10438.08, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11241.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7981.66, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8029.29, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10036.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14549.07, "additional_payer_notes": "181.20% of Medicare Rates" } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC", "code_information": [ { "code": "266", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 59674, "minimum": 11700, "maximum": 119349.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 74593.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 59887.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 91383.8 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 119349.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 59674.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 77577.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 83544.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 59674.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 74593.39, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 108130.57, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 83902.64, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 87125.08, "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": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 62852.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 59674.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 59674.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 95479.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 60480.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 59674.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 51469.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 59294.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 107502.63 } ] } ] }, { "description": "ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC", "code_information": [ { "code": "267", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 46497, "minimum": 4958.88, "maximum": 92995.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 58122.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 46664.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 71399.95 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 92995.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 46497.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 60446.97, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 65096.74, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 46497.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 58122.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 84253.78, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 65375.72, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 67886.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 48974.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 46497.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 46497.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 74396.27, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 47126.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 46497.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4958.88 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 46202.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 84424.05 } ] } ] }, { "description": "EPISTAXIS WITH MCC", "code_information": [ { "code": "150", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13455, "minimum": 9578.145, "maximum": 26911.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16819.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13507.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 19231.84 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 26911.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13455.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 17492.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18838.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13455.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16819.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 24381.95, "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": 18918.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 19645.5, "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": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14175.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13455.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13455.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 21529.31, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13640.77, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13455.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18798.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13373.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24803.05 } ] } ] }, { "description": "EPISTAXIS WITHOUT MCC", "code_information": [ { "code": "151", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 7698, "minimum": 6102.1, "maximum": 20286.4125, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 9623.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 7729.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11275.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 15397.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 7698.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10008.45, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 10778.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 7698.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 9623.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 13950.24, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 10824.53, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 11240.26, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8112.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 7698.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 7698.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 12318.1, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 7806.37, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 7698.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6102.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 7653.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13602.02 } ] } ] }, { "description": "Ercp Duct Stent Placement", "code_information": [ { "code": "43274", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26082.3, "discounted_cash": 7769, "minimum": 414.74, "maximum": 26082.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9712.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 601.37 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 480.54 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "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": 414.74 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11654.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7847.62, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9928.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15539.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10877.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 9712.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 10924.51, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11344.08, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 443.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8236.12, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.74 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 7925.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7381.42, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.74 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 414.74 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7769.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10235.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Ercp Ea Duct/Ampulla Dilate", "code_information": [ { "code": "43277", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11573.3, "discounted_cash": 4934, "minimum": 344.01, "maximum": 21423.8, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 498.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 361.21 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7401.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4983.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6305.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9868.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6908.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6937.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7204.34, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 368.09 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5230.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 5033.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4687.76, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 344.01 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Ercp Remove Forgn Body Duct", "code_information": [ { "code": "43275", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9961, "discounted_cash": 2455, "minimum": 342.14, "maximum": 9961, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 496.1 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 391.95 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.14 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3683.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2480.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3138.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4911.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3438.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 3453.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3585.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 366.09 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2603.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.14 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2505.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2333.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.14 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.14 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Ercp W/Specimen Collection", "code_information": [ { "code": "43260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12593.9, "discounted_cash": 4934, "minimum": 443.24, "maximum": 22868, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 642.7 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 465.4 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 443.24 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7401.72, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4983.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6305.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9868.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6908.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6168.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6937.88, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7204.34, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 474.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5230.55, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 443.24 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 5033.17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4687.76, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 443.24 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 443.24 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4934.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6500.44, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC", "code_information": [ { "code": "391", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12846, "minimum": 12690.7, "maximum": 25693.74, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16058.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 12895.88, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18664.18 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 25693.74, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12846.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 16700.93, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 17985.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12846.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16058.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23278.53, "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": 18062.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18756.43, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13534.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12846.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12846.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20554.99, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13023.56, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12846.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 12690.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12768.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23049.86 } ] } ] }, { "description": "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC", "code_information": [ { "code": "392", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8138, "minimum": 7902.11, "maximum": 16276.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10172.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8170.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11493.75 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16276.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8138.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10579.62, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11393.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8138.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10172.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14746.36, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 11442.27, "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": 11881.73, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8575.23, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8138.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8138.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13021.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8251.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8138.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7902.11 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8089.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14002.19 } ] } ] }, { "description": "Esophagoscopy Flex Remove Fb", "code_information": [ { "code": "43215", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10215.4, "discounted_cash": 2455, "minimum": 320.42, "maximum": 10215.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 464.61 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 336.44 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 320.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3683.91, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2480.5, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3138.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4911.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3438.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3069.93, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 3453.05, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3585.67, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 342.85 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2603.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 320.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2505.06, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2333.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 320.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 320.42 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2455.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3235.33, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc Abd Les Sc 3 Cm/>", "code_information": [ { "code": "22903", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12728.5, "discounted_cash": 3717, "minimum": 362.25, "maximum": 12728.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 525.26 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 380.36 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7435.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 387.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 362.25 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXC ABDL TUM DEEP < 5 CM", "code_information": [ { "code": "22900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10507.2, "discounted_cash": 3717, "minimum": 496.8075, "maximum": 10507.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 840.17 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 496.81 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7435.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 619.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10507.2, "discounted_cash": 3717, "minimum": 496.8075, "maximum": 10507.2, "payers_information": [ { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7435.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 619.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 840.17 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 496.81 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "Exc Back Les Sc 3 Cm/>", "code_information": [ { "code": "21931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11792.5, "discounted_cash": 2113, "minimum": 386.08, "maximum": 11792.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 559.82 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 405.38 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4227.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 413.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 386.08 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXC FACE TUM DEEP 2 CM>", "code_information": [ { "code": "21014", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10507.2, "discounted_cash": 3717, "minimum": 432.61, "maximum": 10507.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 627.28 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.24 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7435.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 462.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10507.2, "discounted_cash": 3717, "minimum": 432.61, "maximum": 10507.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 627.28 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 454.24 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7435.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 462.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 432.61 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc foottoe tum dep 1.5cm>", "code_information": [ { "code": "28041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4375, "discounted_cash": 3717, "minimum": 371.56, "maximum": 4375, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 538.76 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 390.14 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 397.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 4375, "discounted_cash": 3717, "minimum": 371.56, "maximum": 4375, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 538.76 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 390.14 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 397.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 371.56 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4375, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXC FOREARM LES SC < 3 CM", "code_information": [ { "code": "25075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750, "discounted_cash": 2113, "minimum": 471.01, "maximum": 8750, "payers_information": [ { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 682.96 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.56 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4227.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 503.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 8750, "discounted_cash": 2113, "minimum": 471.01, "maximum": 8750, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 682.96 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.56 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4227.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 503.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 471.01 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc rect tum transanal part", "code_information": [ { "code": "45171", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3552, "minimum": 494.41, "maximum": 10500, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 716.89 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 519.13 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5328.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3587.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7104.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 4994.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3623.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3374.85, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10500, "discounted_cash": 3552, "minimum": 494.41, "maximum": 10500, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 716.89 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 519.13 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5328.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3587.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7104.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 4994.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 529.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3623.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3374.85, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 494.41 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXC SHOULDER TUM DEEP 5 CM>", "code_information": [ { "code": "23073", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10627.5, "discounted_cash": 3717, "minimum": 568.5, "maximum": 10627.5, "payers_information": [ { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 608.3 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 824.33 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 596.93 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7435.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 10627.5, "discounted_cash": 3717, "minimum": 568.5, "maximum": 10627.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 824.33 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 596.93 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5576.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3754.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4750.5, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7435.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5204.68, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4647.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5226.99, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5427.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 608.3 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3940.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3791.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3531.75, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 568.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3717.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4897.42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc thighknee les sc < 3 cm", "code_information": [ { "code": "27327", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4375, "discounted_cash": 2113, "minimum": 551.66, "maximum": 4375, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 799.91 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.24 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4227.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 4375, "discounted_cash": 2113, "minimum": 551.66, "maximum": 4375, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 799.91 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 579.24 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4227.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 551.66 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc tr-ext b9+marg >4.0 cm", "code_information": [ { "code": "11406", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7007.2, "discounted_cash": 2113, "minimum": 277.15, "maximum": 7007.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 401.87 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 291.01 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4227.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] }, { "setting": "outpatient", "gross_charge": 7007.2, "discounted_cash": 2113, "minimum": 277.15, "maximum": 7007.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 401.87 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 291.01 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3170.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2134.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2701.1, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4227.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2959.35, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 2642.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 2972.03, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3086.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 296.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2240.65, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2156.1, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2008.13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 277.15 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2113.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 2784.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Exc tr-ext b9+marg 2.1-3cm", "code_information": [ { "code": "11403", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7044.38, "discounted_cash": 906, "minimum": 116.42, "maximum": 7044.38, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 168.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 122.24 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1359.47, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 915.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1158.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1812.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1268.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1132.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 1274.27, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1323.21, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 124.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 960.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 924.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 860.99, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 116.42 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 906.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1193.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Excision Of Anal Lesion(S)", "code_information": [ { "code": "46922", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12281.6, "discounted_cash": 3552, "minimum": 136.71, "maximum": 12281.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 198.23 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.55 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.71 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5328.71, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3587.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4539.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7104.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4973.46, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4440.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 4994.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5186.61, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 146.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3765.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.71 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 3623.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3374.85, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.71 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 136.71 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3552.47, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 4679.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 1", "code_information": [ { "code": "8411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15021.62, "maximum": 20279.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20279.19, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16073.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15021.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 2", "code_information": [ { "code": "8412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27312.42, "maximum": 36871.77, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 36871.77, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29224.29, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27312.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 3", "code_information": [ { "code": "8413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 52320.18, "maximum": 70632.24, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 70632.24, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 55982.59, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52320.18, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT - SOI : 4", "code_information": [ { "code": "8414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 173017.86, "maximum": 233574.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 233574.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 185129.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 173017.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 1", "code_information": [ { "code": "9111", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15548.49, "maximum": 20990.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20990.46, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16636.88, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15548.49, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 2", "code_information": [ { "code": "9112", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 18876.14, "maximum": 25482.79, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25482.79, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20197.47, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18876.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 3", "code_information": [ { "code": "9113", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 29241.8, "maximum": 39476.43, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39476.43, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 31288.73, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29241.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA - SOI : 4", "code_information": [ { "code": "9114", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 54718.12, "maximum": 73869.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 73869.46, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58548.39, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 54718.12, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT", "code_information": [ { "code": "927", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 206342, "minimum": 93065.7825, "maximum": 425696.6313, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 257927.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 207068.18, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 385641.94 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 412684.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 206342.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 268244.7, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 288878.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 206342.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 257927.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 373891.85, "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": 290116.96, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 301259.44, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 217319.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 206342.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 206342.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 330147.33, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 209118.36, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 206342.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 322656 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 205018, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 425696.63 } ] } ] }, { "description": "EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT", "code_information": [ { "code": "933", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 38147, "minimum": 11700, "maximum": 77644.5763, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 47684.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 38285.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 44359.79 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 76295.68, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 38147.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 49592.19, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 53406.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 38147.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 47684.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 69123.89, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 53635.86, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 55695.85, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40180.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 38147.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 38147.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 61036.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 38664.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 38147.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 58851 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 37906.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 77644.58 } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 1", "code_information": [ { "code": "9501", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12415.89, "maximum": 16761.45, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16761.45, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "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": 12415.89, "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": 13285, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12415.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 2", "code_information": [ { "code": "9502", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16736.86, "maximum": 22594.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22594.76, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17908.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16736.86, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 3", "code_information": [ { "code": "9503", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 26055.14, "maximum": 35174.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 35174.44, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27879, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 26055.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS- SOI : 4", "code_information": [ { "code": "9504", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 44744.7, "maximum": 60405.35, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60405.35, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 47876.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 44744.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC", "code_information": [ { "code": "982", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24314, "minimum": 18450, "maximum": 48629.28, "payers_information": [ { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 36371.52 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 48629.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 24314.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 31609.03, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 34040.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 24314.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 30393.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 44058.13, "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": 34186.38, "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": 35499.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 25611.93, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 24314.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 24314.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 38903.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 24645.44, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 24314.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 29125.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 43933.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 30393.3, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 24162.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 24403.82, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC", "code_information": [ { "code": "981", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45832, "minimum": 31899.0375, "maximum": 91665.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 57291.05, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 45997.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 69354.6 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 91665.68, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 45832.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 59582.69, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 64165.98, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 45832.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 57291.05, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 83049.11, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 64440.97, "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": 66915.95, "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": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 48274.41, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 45832.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 45832.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 73332.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 46452.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 45832.84, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 68591.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 45541.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 85306.93 } ] } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CCMCC", "code_information": [ { "code": "983", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17141, "minimum": 9000, "maximum": 44483.49, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 21426.58, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 17205.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23923.85 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 34282.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17141.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 22283.64, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 23997.76, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17141.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 21426.58, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 31059.96, "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": 24100.61, "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": 25026.24, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18057.1, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 17141.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17141.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 27426.02, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 17375.7, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17141.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15561.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17035, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 29935.22 } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 1", "code_information": [ { "code": "7921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 12017.29, "maximum": 16223.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16223.34, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12858.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12017.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 2", "code_information": [ { "code": "7922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15308.9, "maximum": 20667.01, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20667.01, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "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": 15308.9, "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": 16380.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15308.9, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 3", "code_information": [ { "code": "7923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 22449.74, "maximum": 30307.15, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30307.15, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24021.22, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22449.74, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT - SOI : 4", "code_information": [ { "code": "7924", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 38747.72, "maximum": 52309.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52309.42, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "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": 38747.72, "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": 41460.06, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38747.72, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 1", "code_information": [ { "code": "8431", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4519.21, "maximum": 6100.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6100.93, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "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": 4519.21, "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": 4835.55, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4519.21, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 2", "code_information": [ { "code": "8432", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5940.8, "maximum": 8020.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8020.08, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6356.66, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5940.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 3", "code_information": [ { "code": "8433", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11688.66, "maximum": 15779.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15779.69, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12506.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11688.66, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT- SOI : 4", "code_information": [ { "code": "8434", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 16967.96, "maximum": 22906.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 22906.75, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18155.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16967.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 1", "code_information": [ { "code": "1781", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39720.89, "maximum": 53623.2, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53623.2, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 42501.35, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39720.89, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 2", "code_information": [ { "code": "1782", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 43293.42, "maximum": 58446.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 58446.12, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 46323.96, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 43293.42, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 3", "code_information": [ { "code": "1783", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 53704.67, "maximum": 72501.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 72501.3, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 57464, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 53704.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTERNAL HEART ASSIST SYSTEMS- SOI : 4", "code_information": [ { "code": "1784", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 66228.69, "maximum": 89408.73, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 89408.73, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "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": 66228.69, "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": 70864.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 66228.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 1", "code_information": [ { "code": "0091", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 48887.57, "maximum": 65998.22, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 65998.22, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "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": 48887.57, "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": 52309.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 48887.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 2", "code_information": [ { "code": "0092", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 60423.58, "maximum": 81571.83, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 81571.83, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "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": 60423.58, "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": 64653.23, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 60423.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 3", "code_information": [ { "code": "0093", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 110110.47, "maximum": 148649.13, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 148649.13, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 117818.2, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 110110.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)- SOI : 4", "code_information": [ { "code": "0094", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 194638.6, "maximum": 262762.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 262762.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 208263.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 194638.6, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITH CC", "code_information": [ { "code": "038", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 16260, "minimum": 8550, "maximum": 32521.22, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 20325.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 16321.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23407.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 32521.22, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 16260.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 21138.79, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22764.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 16260.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 20325.76, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 29464.23, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 22862.42, "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": 23740.49, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17129.6, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 16260.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 16260.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 26016.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16483.2, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 16260.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 24551.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 16160, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 28914.17 } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITH MCC", "code_information": [ { "code": "037", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 32346, "minimum": 22050, "maximum": 64693.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 40433.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 32463.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 49386.84 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 64693.02, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 32346.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 42050.46, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 45285.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 32346.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 40433.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 58611.88, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 45479.19, "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": 47225.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 34070.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 32346.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 32346.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 51754.42, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 32785.25, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 32346.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 55839.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 32142.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 59592.29 } ] } ] }, { "description": "EXTRACRANIAL PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "039", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11952, "minimum": 5400, "maximum": 23905.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 14940.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 11998.7, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16693.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 23905.46, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 11952.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 15538.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 16733.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 11952.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 14940.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 21658.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 16805.54, "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": 17450.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12592.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 11952.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 11952.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 19124.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 12117.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 11952.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20061 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 11879.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20424.57 } ] } ] }, { "description": "EXTRAOCULAR PROCEDURES EXCEPT ORBIT", "code_information": [ { "code": "115", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15415, "minimum": 15093.8175, "maximum": 30831.22, "payers_information": [ { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22888.01 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 30831.22, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15415.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20040.29, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 21581.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15415.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19269.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 27933.09, "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": 21674.35, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 22506.79, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16239.62, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15415.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15415.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 24664.98, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 15626.81, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15415.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 28531.6 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27473.21 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19269.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15320.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15473.6, "additional_payer_notes": "101.00% of Medicare Rates" } ] } ] }, { "description": "EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE", "code_information": [ { "code": "790", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 57893, "minimum": 8999.99, "maximum": 115786.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 72366.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 58099.95, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 87784.69 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 115786.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 57893.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 75261.12, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 81050.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 57893.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 72366.46, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 104902.42, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 81397.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 84524.03, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 60976.18, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 57893.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 57893.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 92629.07, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 58675.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 57893.17, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8999.99 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 57524.7, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 106677.18 } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 1", "code_information": [ { "code": "0821", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4419.56, "maximum": 5966.41, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5966.41, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "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": 4419.56, "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": 4728.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 2", "code_information": [ { "code": "0822", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5772.24, "maximum": 7792.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7792.52, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "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": 5772.24, "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": 6176.3, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5772.24, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 3", "code_information": [ { "code": "0823", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8121.43, "maximum": 10963.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10963.93, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "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": 8121.43, "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": 8689.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8121.43, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "EYE INFECTIONS AND OTHER EYE DISORDERS - SOI : 4", "code_information": [ { "code": "0824", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14031.48, "maximum": 18942.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 18942.5, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15013.68, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14031.48, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 1", "code_information": [ { "code": "0921", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11178.75, "maximum": 15091.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15091.31, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "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": 11178.75, "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": 11961.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11178.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 2", "code_information": [ { "code": "0922", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14154.46, "maximum": 19108.52, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19108.52, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15145.27, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14154.46, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 3", "code_information": [ { "code": "0923", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 21195.64, "maximum": 28614.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28614.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "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": 21195.64, "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": 22679.33, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21195.64, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES - SOI : 4", "code_information": [ { "code": "0924", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 39182.36, "maximum": 52896.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 52896.19, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "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": 39182.36, "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": 41925.13, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 39182.36, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 1", "code_information": [ { "code": "5311", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4150.29, "maximum": 5602.89, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5602.89, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4440.81, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4150.29, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 2", "code_information": [ { "code": "5312", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5424.53, "maximum": 7323.12, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7323.12, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5804.25, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5424.53, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 3", "code_information": [ { "code": "5313", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8474.44, "maximum": 11440.49, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11440.49, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "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": 8474.44, "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": 9067.65, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8474.44, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM INFECTIONS - SOI : 4", "code_information": [ { "code": "5314", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15745.67, "maximum": 21256.65, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 21256.65, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "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": 15745.67, "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": 16847.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15745.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 1", "code_information": [ { "code": "5301", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4830.88, "maximum": 6521.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6521.69, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "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": 4830.88, "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": 5169.04, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4830.88, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 2", "code_information": [ { "code": "5302", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6392.4, "maximum": 8629.74, "payers_information": [ { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6839.87, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8629.74, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6392.4, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 3", "code_information": [ { "code": "5303", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9625.71, "maximum": 12994.71, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12994.71, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "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": 9625.71, "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": 10299.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9625.71, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM MALIGNANCY - SOI : 4", "code_information": [ { "code": "5304", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14427.96, "maximum": 19477.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19477.75, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15437.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14427.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES", "code_information": [ { "code": "748", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 13993, "minimum": 6300, "maximum": 33314.61, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17491.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14046.47, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 20554.44 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 27986.92, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 13993.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18191.5, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 19590.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 13993.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17491.83, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 25356.15, "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": 19674.8, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20430.45, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14741.84, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 13993.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 13993.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22389.54, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14185.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 13993.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23627.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 13907.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24445.96 } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 1", "code_information": [ { "code": "5141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7944.39, "maximum": 10724.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10724.93, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8500.5, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7944.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 2", "code_information": [ { "code": "5142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11619.76, "maximum": 15686.68, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15686.68, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "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": 11619.76, "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": 12433.14, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11619.76, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 3", "code_information": [ { "code": "5143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15285.58, "maximum": 20635.53, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20635.53, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "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": 15285.58, "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": 16355.57, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15285.58, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES - SOI : 4", "code_information": [ { "code": "5144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 28211.38, "maximum": 38085.36, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 38085.36, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 30186.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 28211.38, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS", "code_information": [ { "code": "864", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9179, "minimum": 7739.13, "maximum": 19440.4425, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11474.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9215.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 12915.84 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18359.46, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9179.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 11933.65, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12851.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9179.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11474.66, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16633.67, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 12906.7, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 13402.41, "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": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9672.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9179.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9179.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14687.57, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9307.18, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9179.73, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7739.13 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9124.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16114.27 } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 1", "code_information": [ { "code": "7221", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 3387.02, "maximum": 4572.48, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4572.48, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "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": 3387.02, "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": 3624.11, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 3387.02, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 2", "code_information": [ { "code": "7222", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4749.25, "maximum": 6411.49, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6411.49, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5081.7, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4749.25, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 3", "code_information": [ { "code": "7223", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6444.35, "maximum": 8699.87, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8699.87, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6895.45, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6444.35, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FEVER AND INFLAMMATORY CONDITIONS- SOI : 4", "code_information": [ { "code": "7224", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8918.62, "maximum": 12040.14, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12040.14, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9542.92, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8918.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 1", "code_information": [ { "code": "3141", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8097.04, "maximum": 10931, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10931, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8663.83, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8097.04, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 2", "code_information": [ { "code": "3142", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 10597.82, "maximum": 14307.06, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14307.06, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "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": 10597.82, "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": 11339.67, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10597.82, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 3", "code_information": [ { "code": "3143", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15322.69, "maximum": 20685.63, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20685.63, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 16395.28, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15322.69, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT & TOE PROCEDURES - SOI : 4", "code_information": [ { "code": "3144", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 25759.37, "maximum": 34775.15, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 34775.15, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "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": 25759.37, "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": 27562.53, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 25759.37, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FOOT PROCEDURES WITH CC", "code_information": [ { "code": "504", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18636, "minimum": 18000, "maximum": 37273.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 23295.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 18706.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 25268.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 37273.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18636.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 24227.63, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 26091.3, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18636.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 23295.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33769.59, "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": 26203.12, "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": 27209.49, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19632.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 18636.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18636.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29818.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18891.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18636.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 23322.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18520.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31492.81 } ] } ] }, { "description": "FOOT PROCEDURES WITH MCC", "code_information": [ { "code": "503", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27519, "minimum": 27346.3, "maximum": 55038.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 34399.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 27619.76, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39237.64 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 55038.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 27519.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 35775.09, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 38527.02, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 27519.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 34399.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 49864.97, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 38692.14, "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": 40178.18, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 28987.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 27519.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 27519.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 44030.88, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 27893.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 27519.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 35996.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 27346.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47492.23 } ] } ] }, { "description": "FOOT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "505", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 17900, "minimum": 17568.7, "maximum": 35801.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 22375.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 17967.29, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 24955.31 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 35801.02, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 17900.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 23270.66, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25060.71, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 17900.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 22375.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 32435.72, "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": 25168.12, "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": 26134.74, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18856.76, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 17900.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 17900.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 28640.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18145.19, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 17900.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 17568.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 17789.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 31492.81 } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 1", "code_information": [ { "code": "3401", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4081.39, "maximum": 5509.88, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5509.88, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4367.09, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4081.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 2", "code_information": [ { "code": "3402", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5213.57, "maximum": 7038.32, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7038.32, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "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": 5213.57, "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": 5578.52, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5213.57, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 3", "code_information": [ { "code": "3403", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7442.96, "maximum": 10048, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10048, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7963.97, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7442.96, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF FEMUR - SOI : 4", "code_information": [ { "code": "3404", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11119.39, "maximum": 15011.18, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15011.18, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11897.75, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11119.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 1", "code_information": [ { "code": "3411", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4419.56, "maximum": 5966.41, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5966.41, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "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": 4419.56, "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": 4728.93, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4419.56, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 2", "code_information": [ { "code": "3412", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5488.14, "maximum": 7408.99, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7408.99, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "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": 5488.14, "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": 5872.31, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5488.14, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 3", "code_information": [ { "code": "3413", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8036.62, "maximum": 10849.44, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10849.44, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8599.18, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8036.62, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE OF PELVIS OR DISLOCATION OF HIP - SOI : 4", "code_information": [ { "code": "3414", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14089.79, "maximum": 19021.22, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19021.22, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "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": 14089.79, "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": 15076.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14089.79, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC", "code_information": [ { "code": "562", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14354, "minimum": 11619.1125, "maximum": 28709.56, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 17943.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14409.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 22248.66 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 28709.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14354.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 18661.21, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20096.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14354.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 17943.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26010.86, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 20182.82, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 20957.98, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15122.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14354.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14354.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 22967.65, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 14551.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14354.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15945.1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14266.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26261.95 } ] } ] }, { "description": "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC", "code_information": [ { "code": "563", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 9254, "minimum": 9012.24, "maximum": 20028.21, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 11568.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 9291.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 13103.11 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 18509.78, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 9254.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 12031.36, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 12956.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 9254.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 11568.61, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 16769.86, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 13012.38, "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": 13512.14, "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": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 9751.32, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 9254.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 9254.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 14807.82, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 9383.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 9254.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 9012.24 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 9199.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 16038.9 } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 1", "code_information": [ { "code": "3421", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 4320.97, "maximum": 5833.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5833.31, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "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": 4320.97, "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": 4623.44, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 4320.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 2", "code_information": [ { "code": "3422", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5791.33, "maximum": 7818.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7818.3, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "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": 5791.33, "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": 6196.72, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5791.33, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 3", "code_information": [ { "code": "3423", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 8404.47, "maximum": 11346.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11346.03, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8992.78, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8404.47, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK - SOI : 4", "code_information": [ { "code": "3424", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 15077.8, "maximum": 20355.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 20355.03, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "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": 15077.8, "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": 16133.25, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15077.8, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "FRACTURES OF FEMUR WITH MCC", "code_information": [ { "code": "533", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15731, "minimum": 10459.1475, "maximum": 31463.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19664.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15790.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23868.26 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 31463.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15731.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20451.13, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22024.3, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15731.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19664.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28505.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 22118.69, "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": 22968.19, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16572.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15731.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15731.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25170.62, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 15947.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15731.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20739.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15634.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27363.75 } ] } ] }, { "description": "FRACTURES OF FEMUR WITHOUT MCC", "code_information": [ { "code": "534", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8393, "minimum": 6361.87, "maximum": 16787, "payers_information": [ { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10911.55, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11750.9, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8393.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10491.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15209.02, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 11801.26, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12254.51, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8844.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8393.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8393.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13429.6, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8510.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8393.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 6361.87 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14606.92 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10491.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8426.96, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11850.74 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8343.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16787, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8393.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "FRACTURES OF HIP AND PELVIS WITH MCC", "code_information": [ { "code": "535", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12978, "minimum": 10478.61, "maximum": 25957.76, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 16223.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 13028.39, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18971.42 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 25957.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 12978.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 16872.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 18170.43, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 12978.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 16223.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 23517.73, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 18248.31, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 18949.16, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 13673.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 12978.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 12978.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 20766.21, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 13157.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 12978.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 18088.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 12899.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23864.55 } ] } ] }, { "description": "FRACTURES OF HIP AND PELVIS WITHOUT MCC", "code_information": [ { "code": "536", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8407, "minimum": 7808.98, "maximum": 16815.92, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10509.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8441.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11515.7 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16815.92, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8407.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10930.35, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11771.14, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8407.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10509.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 15235.22, "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": 11821.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 12275.62, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8859.35, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8407.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8407.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13452.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8525.04, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8407.96, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7808.98 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8357.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14551.29 } ] } ] }, { "description": "FULL TERM NEONATE WITH MAJOR PROBLEMS", "code_information": [ { "code": "793", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 40801, "minimum": 14311.5, "maximum": 81602.72, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 51001.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 40948.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 61584.32 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 81602.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 40801.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 53041.77, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 57121.9, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 40801.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 51001.7, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 73932.06, "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": 57366.71, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 59569.99, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 42975.37, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 40801.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 40801.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 65282.18, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 41353.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 40801.36, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 56723.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 40542.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 74838.04 } ] } ] }, { "description": "FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CCMCC", "code_information": [ { "code": "928", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 69736, "minimum": 41789.88, "maximum": 139473.42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 87170.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 69984.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 101238.93 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 139473.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 69736.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 90657.72, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 97631.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 69736.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 87170.89, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 126362.92, "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": 98049.81, "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": 101815.6, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 73449.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 69736.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 69736.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 111578.74, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 70677.84, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 69736.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 42156 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 69292, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 119850.32 } ] } ] }, { "description": "FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CCMCC", "code_information": [ { "code": "929", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31659, "minimum": 21348.8, "maximum": 63319.04, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 39574.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 31774.4, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 47044.49 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 63319.04, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 31659.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 41157.38, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 44323.33, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 31659.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 39574.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 57367.05, "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": 44513.29, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 46222.9, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 33347.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 31659.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 31659.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 50655.23, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 32089, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 31659.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 21348.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 31459.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 57071.07 } ] } ] }, { "description": "FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY", "code_information": [ { "code": "934", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21926, "minimum": 4460.17, "maximum": 43852.16, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 27407.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 22006.89, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 30614.4 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 43852.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 21926.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 28503.9, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 30696.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 21926.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 27407.6, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 39730.06, "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": 30828.07, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 32012.08, "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": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 23096.34, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 21926.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 21926.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 35081.73, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 22224.78, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 21926.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 4460.17 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 21789, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 38505.57 } ] } ] }, { "description": "Fusion Of Foot Bones - 28730 - OR36028730", "code_information": [ { "code": "28730", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11275, "discounted_cash": 16431, "minimum": 665.4, "maximum": 11275, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 964.83 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 698.67 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 665.4 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 711.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 665.4 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 665.4 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 665.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11275, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Fusion of foot bones - 28735 - ", "code_information": [ { "code": "28735", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7792.87, "discounted_cash": 16431, "minimum": 846.97, "maximum": 7792.87, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1228.11 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 889.32 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "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": 846.97 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 906.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 846.97 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 846.97 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 846.97 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7792.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Fusion of foot bones - 28740 - ", "code_information": [ { "code": "28740", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6624.87, "discounted_cash": 9286, "minimum": 544.17, "maximum": 6624.87, "payers_information": [ { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 582.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 544.17 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 544.17 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 544.17 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 789.05 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 571.38 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "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": 544.17 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6624.87, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 1", "code_information": [ { "code": "2321", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9808.05, "maximum": 13240.87, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13240.87, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 10494.61, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9808.05, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 2", "code_information": [ { "code": "2322", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 11514.81, "maximum": 15544.99, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 15544.99, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "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": 11514.81, "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": 12320.85, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 11514.81, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 3", "code_information": [ { "code": "2323", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 17865.87, "maximum": 24118.92, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24118.92, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "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": 17865.87, "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": 19116.48, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17865.87, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTRIC FUNDOPLICATION - SOI : 4", "code_information": [ { "code": "2324", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 27793.7, "maximum": 37521.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 37521.5, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 29739.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 27793.7, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITH CC", "code_information": [ { "code": "378", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10075, "minimum": 10015, "maximum": 20151.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 12594.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10115.15, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14393.52 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 20151.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 13098.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14106.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 12594.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18257.35, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 14166.57, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 14710.67, "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": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10615.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16121.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10215.3, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10075.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 10716.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10015, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 17691.6 } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITH MCC", "code_information": [ { "code": "377", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18239, "minimum": 18126.3, "maximum": 36479.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 22799.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 18307.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26193.05 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 36479.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 18239.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 23711.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 25535.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 18239.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 22799.59, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 33050.28, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 25644.98, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 26629.92, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19213.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 18239.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 18239.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 29183.47, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 18488.83, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 18239.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 20758.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 18126.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 32626.91 } ] } ] }, { "description": "GASTROINTESTINAL HEMORRHAGE WITHOUT CCMCC", "code_information": [ { "code": "379", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 6700, "minimum": 6661.52, "maximum": 13401.2, "payers_information": [ { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 6700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 8360.37 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11425.34 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 8375.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 6728.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9264.06 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 13401.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 6700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 8710.78, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 9380.84, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 6700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 8375.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 12141.49, "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": 9421.04, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 9782.88, "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": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 7061.21, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 6700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 6700.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 10720.96, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 6794.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 6661.52, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITH CC", "code_information": [ { "code": "389", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 8236, "minimum": 7076.23, "maximum": 16472.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 10295.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 8269.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 11651.76 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 16472.9, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 8236.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 10707.39, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 11531.03, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 8236.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 10295.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 14924.45, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 11580.45, "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": 12025.22, "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": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 8678.73, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 8236.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 8236.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 13178.32, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 8351.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 8236.45, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 7076.23 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 8187.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 14384.41 } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITH MCC", "code_information": [ { "code": "388", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 14855, "minimum": 14764.2, "maximum": 29711.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 18569.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 14911.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 21265.49 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 29711.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 14855.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 19312.54, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 20798.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 14855.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 18569.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 26918.71, "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": 20887.25, "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": 21689.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15650.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 14855.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 14855.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 23769.28, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 15059.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 14855.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 15332.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 14764.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 26376.8 } ] } ] }, { "description": "GASTROINTESTINAL OBSTRUCTION WITHOUT CCMCC", "code_information": [ { "code": "390", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 5868, "minimum": 5244.38, "maximum": 11736.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 7335.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 5892.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 8178.47 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 11736.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 5868.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 7628.57, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 8215.38, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 5868.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 7335.16, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 10633.05, "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": 8250.59, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 8567.47, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 6184.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 5868.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 5868.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 9389.01, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 5951.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 5868.13, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 5244.38 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 5834.4, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 9819.3 } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 1", "code_information": [ { "code": "2461", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 5157.39, "maximum": 6962.48, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6962.48, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5518.41, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 5157.39, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 2", "code_information": [ { "code": "2462", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 6330.92, "maximum": 8546.74, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 8546.74, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "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": 6330.92, "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": 6774.08, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 6330.92, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 3", "code_information": [ { "code": "2463", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9026.75, "maximum": 12186.11, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12186.11, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "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": 9026.75, "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": 9658.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9026.75, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "GASTROINTESTINAL VASCULAR INSUFFICIENCY - SOI : 4", "code_information": [ { "code": "2464", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 13256.55, "maximum": 17896.34, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 17896.34, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "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": 13256.55, "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": 14184.51, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 13256.55, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 1", "code_information": [ { "code": "3161", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 7086.77, "maximum": 9567.14, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9567.14, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "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": 7086.77, "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": 7582.84, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 7086.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 2", "code_information": [ { "code": "3162", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 9594.97, "maximum": 12953.21, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 12953.21, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "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": 9594.97, "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": 10266.62, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 9594.97, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 3", "code_information": [ { "code": "3163", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 14722.67, "maximum": 19875.6, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 19875.6, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "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": 14722.67, "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": 15753.26, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 14722.67, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND & WRIST PROCEDURES - SOI : 4", "code_information": [ { "code": "3164", "type": "APR-DRG" } ], "standard_charges": [ { "setting": "inpatient", "minimum": 24919.77, "maximum": 33641.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 33641.69, "additional_payer_notes": "135% of State Medicaid Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "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": 24919.77, "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": 26664.15, "additional_payer_notes": "107% of State Medicaid Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "case rate", "standard_charge_dollar": 24919.77, "additional_payer_notes": "100% of State Medicaid Rates" } ] } ] }, { "description": "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CCMCC", "code_information": [ { "code": "513", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 15795, "minimum": 13264.3425, "maximum": 31590.46, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 19744.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 15854.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 23716.1 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 31590.46, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 15795.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 20533.8, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 22113.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 15795.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 19744.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 28620.96, "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": 22208.09, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 23061.04, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 16639.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 15795.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 15795.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 25272.37, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 16011.55, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 15795.23, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 19041.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 15697.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27017.42 } ] } ] }, { "description": "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CCMCC", "code_information": [ { "code": "514", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 10476, "minimum": 10413.2, "maximum": 41350.0275, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 13095.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 10517.33, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 15237.7 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 20953.24, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 10476.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 13619.61, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 14667.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 10476.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 13095.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 18983.64, "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": 14730.13, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 15295.87, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 11037.99, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 10476.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 10476.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 16762.59, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 10621.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 10476.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 11933.4 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 10413.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 18296.33 } ] } ] }, { "description": "HAND PROCEDURES FOR INJURIES", "code_information": [ { "code": "906", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19552, "minimum": 14400, "maximum": 49814.9175, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "case rate", "standard_charge_dollar": 24441.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 19625.51, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 27528.82 }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "case rate", "standard_charge_dollar": 39105.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "case rate", "standard_charge_dollar": 19552.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "case rate", "standard_charge_dollar": 25418.82, "additional_payer_notes": "130.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Commercial", "methodology": "case rate", "standard_charge_dollar": 27374.12, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "case rate", "standard_charge_dollar": 19552.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "case rate", "standard_charge_dollar": 24441.18, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial", "methodology": "case rate", "standard_charge_dollar": 35429.93, "additional_payer_notes": "181.20% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "case rate", "standard_charge_dollar": 27491.43, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "case rate", "standard_charge_dollar": 28547.29, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "case rate", "standard_charge_dollar": 20597.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "case rate", "standard_charge_dollar": 19552.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "case rate", "standard_charge_dollar": 19552.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "NATIONAL HEALTHCARE SOLUTIONS, INC (NHSI)", "plan_name": "NATIONAL HEALTHCARE SOLUTIONS, INC Commercial", "methodology": "case rate", "standard_charge_dollar": 31284.7, "additional_payer_notes": "160.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "case rate", "standard_charge_dollar": 19819.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "case rate", "standard_charge_dollar": 19552.94, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "case rate", "standard_charge_dollar": 22813 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "case rate", "standard_charge_dollar": 19431.2, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "case rate", "standard_charge_dollar": 39164.13 } ] } ] }, { "description": "Hc Actinotherapy Ultraviolet Light", "code_information": [ { "code": "96900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 251.64, "discounted_cash": 47, "minimum": 10.61, "maximum": 251.64, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.14 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 251.64, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 251.64, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 59.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.4, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.61 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Activity Therapy, Per 15 Min", "code_information": [ { "code": "H2032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408, "minimum": 43.98, "maximum": 408, "payers_information": [ { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.98, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Dup-Scan Artl Infl&Ven O/F Pen Vsl Compl", "code_information": [ { "code": "93980", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1678, "discounted_cash": 133, "minimum": 127.11, "maximum": 1678, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.25, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 241.14 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 249.45 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 166.3 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 135.14, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 170.97, "additional_payer_notes": "127.78% 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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 267.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.32, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 167.25, "additional_payer_notes": "125.00% 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": 177.94 }, { "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": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 141.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 136.48, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 127.11, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 166.3 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 133.8, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 176.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Vnpnxr 3 Years/> Phys/Qhp Skill", "code_information": [ { "code": "36410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1447.43, "minimum": 15.49, "maximum": 1447.43, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.46 }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.26 }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.57 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.49 } ] } ] }, { "description": "Hc 2D Tee W Or W/O Fol W/Con,In", "code_information": [ { "code": "C8925", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4479.02, "discounted_cash": 1003, "minimum": 953.1445, "maximum": 4479.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1254.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1504.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1013.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1282.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2006.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1404.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1254.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1063.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1023.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 953.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 2D Tte W Or W/O Fol W/Con Complete - 93307 - 48300011", "code_information": [ { "code": "93307", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2600.03, "discounted_cash": 305, "minimum": 129.18, "maximum": 2600.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 381.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 187.31 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 226.07 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 308.43, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 390.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 610.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 381.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 323.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 311.49, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 290.11, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 129.18 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 305.38, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 402.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc 2D Tte W Or W/O Fol W/Con Complete - C8923 - 48300011", "code_information": [ { "code": "C8923", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2600.03, "discounted_cash": 1003, "minimum": 780.009, "maximum": 2600.03, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1254.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1504.97, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1013.34, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1282.06, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2006.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1404.63, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1254.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1063.51, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1023.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 953.14, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1003.31, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1321.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Abdom Paracentesis Dx/Ther W Imaging Guidance", "code_information": [ { "code": "49083", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6232.5, "discounted_cash": 1160, "minimum": 89.72, "maximum": 6232.5, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2321.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 89.72 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.72 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.09 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 94.34 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 89.72 }, { "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" } ] } ] }, { "description": "Hc Abdom Paracentesis Dx/Ther W/O Imaging Guidance", "code_information": [ { "code": "49082", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5070.9, "discounted_cash": 1160, "minimum": 58.45, "maximum": 5070.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 84.75 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 61.5 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1172.42, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1483.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2321.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1625.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1451.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1230.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1184.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1102.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.45 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1160.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1529.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Ablate L/R Atrial Fibril W Isolated Pulm Vein", "code_information": [ { "code": "93657", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20401.3, "minimum": 329.97, "maximum": 20401.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 478.46 }, { "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 Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 353.07 }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 329.97 } ] } ] }, { "description": "Hc Actin Smooth Muscle Antibody Each", "code_information": [ { "code": "86015", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 60.25, "discounted_cash": 12, "minimum": 11.4475, "maximum": 60.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.72 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 11.53 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 12.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 11.53 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.45, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.53 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Adjacent Tissue Trns/Reargmt F/C/C/M/N/A/G/H/F 10Sqcm/&Lt", "code_information": [ { "code": "14040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6120.83, "discounted_cash": 2640, "minimum": 483.82, "maximum": 6120.83, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3300.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 701.54 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 508.01 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "case rate", "standard_charge_dollar": 3600, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3374.39, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5281.44, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3697.01, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 3300.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2799.16, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 2693.53, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2508.68, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 483.82 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 2640.72, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 3478.75, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Admin Influenza Virus Vac - G0008 - 77100008 - 77100008", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 265.73, "discounted_cash": 59, "minimum": 25, "maximum": 265.73, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 74.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 119.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 61.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 56.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Admin Pneumococcal Vac - G0009 - 77100009 - 77100009", "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 265.73, "discounted_cash": 59, "minimum": 56.924, "maximum": 265.73, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 74.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 60.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 76.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 119.84, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 83.89, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 74.9, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.52, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 61.12, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 56.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 59.92, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 78.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Ag Detect Nos, Eia, Mult Step", "code_information": [ { "code": "87449", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 194.86, "discounted_cash": 11, "minimum": 9.64, "maximum": 194.86, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.98 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 9.64 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 10.31 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.38, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Agent Nos Assay W/Optic", "code_information": [ { "code": "87899", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80.35, "discounted_cash": 16, "minimum": 5.59, "maximum": 80.35, "payers_information": [ { "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.17, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.11 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 24.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.53, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.14, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 22.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.46 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.98 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 16.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.07, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.27, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 } ] } ] }, { "description": "Hc Airway Inhalation Treatment", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1539.93, "discounted_cash": 280, "minimum": 16.78, "maximum": 1539.93, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 350.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.33 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.62 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 283.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 358.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 560.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 392.36, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 350.33, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 297.08, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 285.87, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 266.25, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.78 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 280.26, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 369.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Allergen Spec Ige Quant,Each", "code_information": [ { "code": "86003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 74.59, "discounted_cash": 5, "minimum": 4.959, "maximum": 74.59, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.71 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.67, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.44, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.53, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.53, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 5.32, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.96, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Allergen Specific Igg", "code_information": [ { "code": "86001", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39.1, "discounted_cash": 7, "minimum": 4.54, "maximum": 39.1, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.96 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "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": 4.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.73, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.9, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.99, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 9.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 10.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 7.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.43, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.54 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.82, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.3, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Alpha-1-Antitrypsin, Pheno", "code_information": [ { "code": "82104", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105.55, "discounted_cash": 14, "minimum": 13.737, "maximum": 105.55, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.4 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.32 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "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": 14.76 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.69, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.92, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.24, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 20.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.79 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.33, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.05, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Alpha-1-Antitrypsin, Total", "code_information": [ { "code": "82103", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 167, "discounted_cash": 13, "minimum": 12.768, "maximum": 167, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.87 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.76 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 13.7 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.17, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.82, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 18.9 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 13.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.44, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Alpha-Fetoprotein, Serum", "code_information": [ { "code": "82105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 371.25, "discounted_cash": 16, "minimum": 15.9315, "maximum": 371.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 141.43 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 89.25 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 97.54 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.16, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.54, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.96, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 23.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.37 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.78, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 97.54 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.09, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amino Acid Single Qual", "code_information": [ { "code": "82127", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 126.5, "discounted_cash": 14, "minimum": 13.471, "maximum": 126.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.52 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.31 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "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": 14.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.12, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.73, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 19.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 14.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.47, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.15 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Amp Mtcrpl W/Finger/Thumb W/Wo Inteross Transfer", "code_information": [ { "code": "26910", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10864.2, "discounted_cash": 4187, "minimum": 487.57, "maximum": 10864.2, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 521.7 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 487.57 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 487.57 }, { "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 487.57 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 706.98 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 511.95 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 487.57 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8375.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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" } ] } ] }, { "description": "Hc Amputation Of Finger/Thumb", "code_information": [ { "code": "26951", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18107, "discounted_cash": 4187, "minimum": 374.88, "maximum": 18107, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 543.58 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 393.62 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 374.88 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4229.59, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5351.18, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8375.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5862.79, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5234.64, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 401.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4438.97, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 374.88 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4271.46, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3978.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 374.88 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4187.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5516.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Aortobifemoral W Cath", "code_information": [ { "code": "75630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15737.5, "discounted_cash": 4041, "minimum": 104.04, "maximum": 15737.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 150.86 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 426.22 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8082.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4121.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3839.08, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Aortogram Thor Serial", "code_information": [ { "code": "75605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18444.7, "discounted_cash": 7121, "minimum": 98.32, "maximum": 18444.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8902.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 142.56 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 390.09 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 98.32 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14243.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8902.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 105.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 98.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6765.69, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.32 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Extremity Unilat", "code_information": [ { "code": "75710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17830.9, "discounted_cash": 4041, "minimum": 130.84, "maximum": 17830.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 189.72 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 397.1 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 130.84 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8082.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 140 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 130.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4121.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3839.08, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 130.84 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Intern Mammary", "code_information": [ { "code": "75756", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10698.5, "discounted_cash": 4041, "minimum": 143.9, "maximum": 10698.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 208.66 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 590.7 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 143.9 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4081.55, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5163.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8082.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5657.6, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5051.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 153.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4283.61, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 143.9 }, { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4121.96, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3839.08, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4041.14, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5323.6, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angio Visceral Selectv/Subselec", "code_information": [ { "code": "75726", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27028.5, "discounted_cash": 7121, "minimum": 121.45, "maximum": 27028.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8902.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 176.1 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 388.93 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 121.45 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7193, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9100.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14243.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9970.49, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8902.23, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 129.95 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7549.09, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 121.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 7264.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6765.69, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 121.45 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7121.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9381.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Angiotensin I Enzyme Test", "code_information": [ { "code": "82164", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 173, "discounted_cash": 14, "minimum": 13.87, "maximum": 173, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.25, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.59 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.52 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.75, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.66, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.25, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 20.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 14.89, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.87, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.89 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antegrade Urography Radiological Supvj & Interpj", "code_information": [ { "code": "74425", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1785.65, "discounted_cash": 446, "minimum": 48.23, "maximum": 1785.65, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 69.93 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.59 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 48.23 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 893, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 51.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 48.23 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 424.18, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.23 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibiotic Sens,Enzyme Detection,Each", "code_information": [ { "code": "87185", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.75, "discounted_cash": 4, "minimum": 1, "maximum": 23.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.41 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.27 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "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": 1 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.8, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.5, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.65, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.04 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.04, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4.85, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.51, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.26, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibiotic Sens,Mic,Each", "code_information": [ { "code": "87186", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 297, "discounted_cash": 8, "minimum": 8.2175, "maximum": 297, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.88 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.05, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 8.82, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.22, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.62 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 11.4, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibody Detection Nos If", "code_information": [ { "code": "87299", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 119, "discounted_cash": 16, "minimum": 11.59, "maximum": 119, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% 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": 24.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 20.57, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 22.64 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.4 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.07, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 16.42, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.59 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antibody Treponema Pallidum", "code_information": [ { "code": "86780", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 170.95, "discounted_cash": 13, "minimum": 9.12, "maximum": 170.95, "payers_information": [ { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.97 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.86, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.92, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.48, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.54, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 18.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 13.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.58, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.12 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.44, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.22 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Antihuman Globulin Dir Ea Antiserum", "code_information": [ { "code": "86880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 331.67, "discounted_cash": 75, "minimum": 5.5, "maximum": 331.67, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.13 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 113.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 76.26, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 96.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 105.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 94.38, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 106.15, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 110.23, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 80.03, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 77.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 71.73, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 75.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 99.46, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antihuman Globulin Indir Qual Ea Reagent Cell", "code_information": [ { "code": "86885", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1110.75, "discounted_cash": 218, "minimum": 5.84, "maximum": 1110.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.47 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.63 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "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": 5.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 436.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 222.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.15, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.84 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antihuman Globulin Indirect Ea Antibody Titer", "code_information": [ { "code": "86886", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1110.75, "discounted_cash": 218, "minimum": 4.84, "maximum": 1110.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "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": 4.84 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 327.08, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 278.63, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 436.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 305.27, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 272.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 306.58, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 318.35, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 231.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 222.41, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.15, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 218.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 287.25, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antineutrophil Cytoplasmic Antb Titer Ea Antb", "code_information": [ { "code": "86037", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 60.25, "discounted_cash": 12, "minimum": 11.4475, "maximum": 60.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.47 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.65 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.06, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.77, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.45, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.87, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antinuclear Antibodies", "code_information": [ { "code": "86038", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 178, "discounted_cash": 12, "minimum": 11.4855, "maximum": 178, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.69 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.11, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.82, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.49, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.93, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antinuclear Antibodies Titer", "code_information": [ { "code": "86039", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 238.75, "discounted_cash": 11, "minimum": 10.602, "maximum": 238.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.5 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.96 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "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": 11.38 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.26, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.95, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 15.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 11.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.6, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antistreptolysin O Titer", "code_information": [ { "code": "86060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 170, "discounted_cash": 7, "minimum": 6.935, "maximum": 170, "payers_information": [ { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.94, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.62, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.58 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "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": 7.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 9.33, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 9.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 10.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.74, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.3, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 7.45, "additional_payer_notes": "102.00% of Medicare Rates" } ] } ] }, { "description": "Hc Antithrombin Iii Test,Activ", "code_information": [ { "code": "85300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 190.35, "discounted_cash": 11, "minimum": 11.2575, "maximum": 190.35, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.1 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.14, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.7, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.56, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.26, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.01 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.61, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Antithrombin Iii Test,Antigen", "code_information": [ { "code": "85301", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 104, "discounted_cash": 10, "minimum": 10.2695, "maximum": 104, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.99 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.04 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "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": 11.03 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.92, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.81, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 15.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.78 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 11.03, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.27, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.24, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Anus Surgery Procedure Unlisted", "code_information": [ { "code": "46999", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4354.05, "discounted_cash": 1190, "minimum": 1130.709, "maximum": 4354.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1487.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1785.33, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1202.12, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1520.9, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2380.44, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1666.31, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1487.78, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 1673.45, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1737.72, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1261.63, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 1214.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1130.71, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 1190.22, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1567.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Finger Splint Static", "code_information": [ { "code": "29130", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 839.8, "discounted_cash": 170, "minimum": 32.04, "maximum": 839.8, "payers_information": [ { "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 32.04 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 46.46 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 33.64 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 32.04 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 839.8, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 340.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 34.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 32.04 } ] } ] }, { "description": "Hc Apply Forearm Splint Static", "code_information": [ { "code": "29125", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 923.78, "discounted_cash": 170, "minimum": 75.84, "maximum": 923.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 109.97 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.63 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": "case rate", "standard_charge_dollar": 923.78, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 340.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 75.84 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Long Arm Splint", "code_information": [ { "code": "29105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1052.19, "discounted_cash": 207, "minimum": 95.06, "maximum": 1052.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 137.84 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 99.81 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 95.06 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 1052.19, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 415.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 101.71 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 95.06 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 212.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 197.58, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.06 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Long Leg Splint", "code_information": [ { "code": "29505", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1052.19, "discounted_cash": 207, "minimum": 98.8, "maximum": 1052.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 143.26 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 103.74 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 98.8 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "case rate", "standard_charge_dollar": 1052.19, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 415.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 105.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 98.8 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 212.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 197.58, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 98.8 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Apply Lower Leg Splint", "code_information": [ { "code": "29515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1052.19, "discounted_cash": 207, "minimum": 81.17, "maximum": 1052.19, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 117.7 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 85.23 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": "case rate", "standard_charge_dollar": 1052.19, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 210.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 265.76, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 415.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 291.17, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 259.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 220.46, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 212.14, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 197.58, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 81.17 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 207.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 273.98, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Abo", "code_information": [ { "code": "86900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 839.8, "discounted_cash": 170, "minimum": 2.73, "maximum": 923.78, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.96 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.66 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 2.73 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 171.98, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 217.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 340.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 238.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 212.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 2.92 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 180.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 2.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 173.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 161.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.73 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 170.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 224.32, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Rbc Antigens", "code_information": [ { "code": "86905", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1735.26, "discounted_cash": 458, "minimum": 3.84, "maximum": 1735.26, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.57 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 3.84 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 917.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 642.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 573.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 4.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 486.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 3.84 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 467.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 435.82, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Blood Typing, Rh (D)", "code_information": [ { "code": "86901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 252.1, "discounted_cash": 47, "minimum": 2.82, "maximum": 277.31, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.09 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 61.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.91, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 59.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 67.19, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 69.77, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.02 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.66, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 48.75, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 45.4, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.82 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 47.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 62.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Antibody Identification", "code_information": [ { "code": "86870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2169.08, "discounted_cash": 458, "minimum": 18.96, "maximum": 2169.08, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.49 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.61 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 18.96 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 463.35, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 586.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 917.52, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 642.26, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 573.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 20.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 486.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 467.94, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 435.82, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.96 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 458.76, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 604.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arc Rbc Antibody Screen", "code_information": [ { "code": "86850", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 357, "discounted_cash": 66, "minimum": 2.98, "maximum": 357, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 83.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.32 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 100.04, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 67.36, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 85.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 133.38, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 93.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 83.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 93.77, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 97.37, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.19 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 70.69, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 68.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 63.36, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.98 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 66.69, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 87.85, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arterial Line Insertion", "code_information": [ { "code": "36620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1321.4, "minimum": 60.35, "maximum": 1321.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 87.51 }, { "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": "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 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.35 } ] } ] }, { "description": "Hc Arthrocentesis Aspir&/Inj Interm Jt/Burs W/Us", "code_information": [ { "code": "20606", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3172.95, "discounted_cash": 903, "minimum": 45.05, "maximum": 3172.95, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1129.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.32 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 47.3 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "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": 45.05 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1355.15, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 912.46, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1154.43, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1806.86, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1264.8, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 1129.29, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 1270.22, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 1319.01, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 48.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 957.64, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 921.5, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 858.26, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 45.05 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 903.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 1190.13, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrocentesis Aspir&/Inj Major Jt/Bursa W/Us", "code_information": [ { "code": "20611", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1558.05, "discounted_cash": 392, "minimum": 52.87, "maximum": 1558.05, "payers_information": [ { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.66 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 55.51 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 52.87 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 785.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 56.57 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 373.22, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 52.87 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Ankle", "code_information": [ { "code": "73615", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1369.02, "discounted_cash": 446, "minimum": 79.92, "maximum": 1369.02, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 115.88 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 79.92 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 893, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 85.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 79.92 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 424.18, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 79.92 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Knee Joint", "code_information": [ { "code": "73580", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2148.09, "discounted_cash": 446, "minimum": 76.45, "maximum": 2148.09, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 110.85 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 104.25 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 893, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 81.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 424.18, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.45 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Arthrogram Of Shoulder", "code_information": [ { "code": "73040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1602.23, "discounted_cash": 446, "minimum": 53.81, "maximum": 1602.23, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.02 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 76.35 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 669.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 450.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 570.55, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 893, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 625.1, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 558.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 57.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 473.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 455.43, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 424.18, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 53.81 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 446.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 588.2, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Asp/Drain Large Joint/Bursa", "code_information": [ { "code": "20610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1945.83, "discounted_cash": 392, "minimum": 65.68, "maximum": 1945.83, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 95.24 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.96 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 785.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 552.36, "additional_payer_notes": "140.60% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 573.58, "additional_payer_notes": "146.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 70.28 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 373.22, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 65.68 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aspergillus Ag Eia", "code_information": [ { "code": "87305", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 168.94, "discounted_cash": 11, "minimum": 6.93, "maximum": 168.94, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.05 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.09 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.31, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.77, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 14.98, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.7, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.38, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.93 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aspergillus Antibody", "code_information": [ { "code": "86606", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 127, "discounted_cash": 15, "minimum": 14.2975, "maximum": 127, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.26 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.18 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 22.58, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.2, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.1, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.81, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 21.16 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 15.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.3, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.35 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Aspirat/Injection Ganglion Cyst(S)", "code_information": [ { "code": "20612", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1475.95, "discounted_cash": 392, "minimum": 54.36, "maximum": 1475.95, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 78.82 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 57.08 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 396.79, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 502.01, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 785.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 550, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 491.08, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 416.43, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 400.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 373.22, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 54.36 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 392.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 517.53, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Alkaline Phosphatase", "code_information": [ { "code": "84075", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.5, "discounted_cash": 5, "minimum": 4.74, "maximum": 142.5, "payers_information": [ { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.49, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 5.28, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.92, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.87 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.85 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 } ] } ] }, { "description": "Hc Assay Alkaline Phosphatase ,Isoenzymes", "code_information": [ { "code": "84080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 107.95, "discounted_cash": 14, "minimum": 14.041, "maximum": 107.95, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.87 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.89, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.69, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.04, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.47, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Anti-Mullerian Horm", "code_information": [ { "code": "82166", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42, "discounted_cash": 38, "minimum": 12.6, "maximum": 42, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.81 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "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": 38.62 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 42, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 42 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.62 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 39.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.69, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.62 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.62 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 42, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Biotinidase", "code_information": [ { "code": "82261", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 165.87, "discounted_cash": 16, "minimum": 15.9, "maximum": 165.87, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.06 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.81 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 15.9 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.04, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.56, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.74, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.62, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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": 17.01 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": 15.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 17.21, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.03, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.87, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Blood Carbon Dioxide", "code_information": [ { "code": "82374", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 118.23, "discounted_cash": 4, "minimum": 1.56, "maximum": 118.23, "payers_information": [ { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6.86 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.67 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4.98, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.43, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.26 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 1.56 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.32, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.93, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.76, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.83, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Blood Carbon Monoxide", "code_information": [ { "code": "82375", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 155.69, "discounted_cash": 12, "minimum": 11.704, "maximum": 155.69, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.23 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.22 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.48, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.44, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.74, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.64, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 17.32 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.99 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.7, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.23, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Carbamazepine Free", "code_information": [ { "code": "80157", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66.25, "discounted_cash": 13, "minimum": 8.79, "maximum": 66.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.75 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.54 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "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": 8.79 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.88, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.38, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.5, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.55, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.56, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 18.63 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.41 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.05, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 13.52, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.59, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.79 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.25, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.45, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay For Calprotectin Fecal", "code_information": [ { "code": "83993", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 366.28, "discounted_cash": 19, "minimum": 13.96, "maximum": 366.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.24 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.32 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.45, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.83, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.08, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.48, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 24.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 27.6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 28.66 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.94 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 20.02, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.65, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.96 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.63, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.86, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Glucose, Body Fluid", "code_information": [ { "code": "82945", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 285, "discounted_cash": 3, "minimum": 2.63, "maximum": 285, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "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": 2.63 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.97, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.86, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 4.91, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.74 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.81 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.17, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4.01, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.73, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 2.63 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Growth Hormone (Hgh)", "code_information": [ { "code": "83003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 121.7, "discounted_cash": 16, "minimum": 15.8365, "maximum": 121.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 24.66 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 23.53 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "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": 17.01 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.01, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.84, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.34, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.34, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 20.84, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 23.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 24.34 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 17.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 17, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.84, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.01 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 16.67, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Myeloperoxidase", "code_information": [ { "code": "83876", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 254.3, "discounted_cash": 50, "minimum": 15.13, "maximum": 254.3, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 63.58, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.94 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.89 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "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": 15.13 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 76.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 51.37, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 64.99, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 101.72, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 71.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 63.58, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 71.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 74.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.19 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 53.91, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.13 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 51.88, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 48.32, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.13 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.13 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 50.86, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 67, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of 5-Hiaa", "code_information": [ { "code": "83497", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.7, "discounted_cash": 12, "minimum": 11.61, "maximum": 38.7, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.07 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.05 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.8, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.06, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.67, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 13.16, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.26, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.15 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Acetaminophen - G0480 - 30100036", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 629.37, "discounted_cash": 114, "minimum": 63.95, "maximum": 629.37, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.73 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 228.86, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 116.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 108.71, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Acth", "code_information": [ { "code": "82024", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 372, "discounted_cash": 38, "minimum": 36.689, "maximum": 372, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 48.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 57.12 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 55.39 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "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": 39.39 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 57.93, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 39.01, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 49.35, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 77.24, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 54.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 48.28, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 54.3 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 56.39 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 42.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.94, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 39.39, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 36.69, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.39 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.62, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 50.88, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Aldolase", "code_information": [ { "code": "82085", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 70.85, "discounted_cash": 9, "minimum": 9.2245, "maximum": 70.85, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.36 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.25 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "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": 9.9 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.81, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.42, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.59, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 13.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.18 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.59 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.29, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 9.9, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.22, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.9 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Aldosterone", "code_information": [ { "code": "82088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 297.5, "discounted_cash": 40, "minimum": 38.7125, "maximum": 297.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 50.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 60.26 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 58.47 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 61.13, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 41.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 52.07, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 81.5, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.05, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 50.94, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 57.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 59.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 44.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 43.2, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 41.57, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 38.71, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 41.56 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 40.75, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 53.68, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Amikacin", "code_information": [ { "code": "80150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 269.11, "discounted_cash": 15, "minimum": 14.326, "maximum": 269.11, "payers_information": [ { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.23, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.16, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.98, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 15.38, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.33, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 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": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.38 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.85, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.3 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.88 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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" } ] } ] }, { "description": "Hc Assay Of Ammonia", "code_information": [ { "code": "82140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 399.09, "discounted_cash": 14, "minimum": 13.8415, "maximum": 399.09, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.55 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.96 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.14, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.86 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Amphetamines - G0480 - 30100323", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 572.15, "discounted_cash": 114, "minimum": 63.95, "maximum": 629.37, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 92.73 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 67.15 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 171.65, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 115.57, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 146.22, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 228.86, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 160.2, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 143.04, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 160.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 167.07 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 68.43 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 121.3, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 116.72, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 108.71, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 63.95 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 150.74, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Amylase", "code_information": [ { "code": "82150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 338.25, "discounted_cash": 6, "minimum": 6.156, "maximum": 338.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.54 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.75 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.54, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.28, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.96, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.07, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.16, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.54, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Apolipoprotein", "code_information": [ { "code": "82172", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 119.4, "discounted_cash": 21, "minimum": 15.09, "maximum": 119.4, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.88 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 16.11 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.95, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42.18, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.53, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.36, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 21.51, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.04, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.09 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.78, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Arsenic", "code_information": [ { "code": "82175", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 138.5, "discounted_cash": 18, "minimum": 18.0215, "maximum": 138.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 23.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.06 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.87 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.16, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.24, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 37.94, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.56, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 23.71, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (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 Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.11, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "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": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 19.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 18.97, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 24.99, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ascorbic Acid", "code_information": [ { "code": "82180", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.17, "discounted_cash": 9, "minimum": 9.3955, "maximum": 146.17, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.63 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.68 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "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": 10.09 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.84, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.99, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 12.64, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.78, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.85, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 12.36, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 13.91 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.44 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.48, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.4, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.89, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.03, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Chloride", "code_information": [ { "code": "82435", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 136.13, "discounted_cash": 4, "minimum": 3.45, "maximum": 136.13, "payers_information": [ { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.06, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "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": 3.45 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.9, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.65, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.88, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.2, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6.47 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.72 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.69 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.88, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.37, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.6, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 3.45 } ] } ] }, { "description": "Hc Assay Of Blood Lipoprotein,Hdl Cholest", "code_information": [ { "code": "83718", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 192.5, "discounted_cash": 8, "minimum": 7.75, "maximum": 192.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.24 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.21 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.29, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.27, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.47, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.47, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 10.24, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 11.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 11.96 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 8.35, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.78, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 8.19, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 10.79, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Lipoprotein,Ldl Cholest", "code_information": [ { "code": "83721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 190.63, "discounted_cash": 10, "minimum": 9.43, "maximum": 190.63, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.67 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.03 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "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": 9.43 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.75, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.61, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.42, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.13, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 14.76 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.09 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.13, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 10.71, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 9.98, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.83, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Osmolality", "code_information": [ { "code": "83930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 258.5, "discounted_cash": 6, "minimum": 6.2795, "maximum": 258.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.79 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.98 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.92, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.22, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.25, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 9.29 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.65 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.22 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 7.01, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.28, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.75 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.71, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Blood Pku", "code_information": [ { "code": "84030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 186, "discounted_cash": 5, "minimum": 5.225, "maximum": 186, "payers_information": [ { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.23, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.25, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.13 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "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": 5.61 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.25, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.03, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.7, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.88, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 7.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.83, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 5.61, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.5, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of C-Peptide", "code_information": [ { "code": "84681", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 136.9, "discounted_cash": 20, "minimum": 19.7695, "maximum": 136.9, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.67 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.38 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 31.22, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.62, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.13, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 26.01, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 29.26 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.38 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 21.89 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 22.06, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.77, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 27.41, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcitonin", "code_information": [ { "code": "82308", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 179.35, "discounted_cash": 26, "minimum": 25.4505, "maximum": 179.35, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 33.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 39.61 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 38.2 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 40.19, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 27.06, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 34.23, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 53.58, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 37.51, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 33.49, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 37.67 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 39.11 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 29.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 28.4, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 27.33, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 27.32 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 26.79, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 35.29, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcium In Urine", "code_information": [ { "code": "82340", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 170, "discounted_cash": 6, "minimum": 5.7285, "maximum": 170, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.92 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.05, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.09, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.71, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.06, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 7.54, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 8.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.58 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.39, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6.15, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.73, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 7.94, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcium, Ionized", "code_information": [ { "code": "82330", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 242, "discounted_cash": 13, "minimum": 12.996, "maximum": 242, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 17.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.23 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.15 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "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": 13.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.82, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.48, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.36, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 17.1, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 19.23 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.97 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.93 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 13.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Calcium, Total", "code_information": [ { "code": "82310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 162.28, "discounted_cash": 5, "minimum": 4.7, "maximum": 162.28, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.82 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.38 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.74, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.21, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.59, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.22, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 6.45, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 7.25 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.53 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.03 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.47, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 5.26, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.9, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.7 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.8, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Carbamazepine Total", "code_information": [ { "code": "80156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468.75, "discounted_cash": 14, "minimum": 13.8415, "maximum": 468.75, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.98 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "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": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.46 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "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": 14.47 }, { "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 Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "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": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.14, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.4, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 18.21, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 20.49 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 21.27 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.48 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 15.44, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 14.86, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.47 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 19.19, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ceruloplasmin", "code_information": [ { "code": "82390", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 177.25, "discounted_cash": 10, "minimum": 10.203, "maximum": 177.25, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 15.89 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.92 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "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": 10.96 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.11, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.85, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 13.72, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.48, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.04, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 13.43, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 15.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.68 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 11.73 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.38, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 10.95, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.2, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Chromium", "code_information": [ { "code": "82495", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 148.05, "discounted_cash": 20, "minimum": 19.266, "maximum": 148.05, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 25.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 30 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 28.77 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "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": 20.69 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 30.42, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.48, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 25.91, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 40.56, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.39, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 25.35, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 28.51 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 29.61 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 22.14 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 21.5, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 20.69, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 19.27, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 20.69 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 26.72, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Ck (Cpk)", "code_information": [ { "code": "82550", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 300.85, "discounted_cash": 6, "minimum": 6.1845, "maximum": 300.85, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 9.63 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 8.8 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Blue Shield Of Promise", "plan_name": "Blue Shield Of Promise Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.77, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.58, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.32, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.02, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.11, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 8.14, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 9.15 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 9.5 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.1 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.9, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 6.64, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.18, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 8.58, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Copper", "code_information": [ { "code": "82525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 128.49, "discounted_cash": 12, "minimum": 11.7895, "maximum": 128.49, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 15.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.36 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 17.35 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "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": 12.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.62, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.53, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 15.86, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.82, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.37, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 15.51, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 17.45 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 18.12 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.15, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 12.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 11.79, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 12.66 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 16.35, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Cpk In Blood", "code_information": [ { "code": "82552", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 325, "discounted_cash": 13, "minimum": 12.7205, "maximum": 325, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 19.81 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 18.77 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "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": 13.66 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 20.09, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.52, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.11, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.78, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.75, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 16.74, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 18.83 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 19.55 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 14.62 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 14.19, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 13.66, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 12.72, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 13.66 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 17.64, "additional_payer_notes": "131.74% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Creatine", "code_information": [ { "code": "82540", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 149, "discounted_cash": 4, "minimum": 4.408, "maximum": 149, "payers_information": [ { "payer_name": "Employer Direct Health Care", "plan_name": "Employer Direct Healthcare Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.5, "additional_payer_notes": "140.00% of Medicare Rates" }, { "payer_name": "Epic Health Plan", "plan_name": "Epic Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services (Tricare)", "plan_name": "Health Net Federal Service Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Health Net Federal Services Prison (CDCR)", "plan_name": "Health Net Federal Services Prison", "methodology": "fee schedule", "standard_charge_dollar": 5.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial (Enhanced PPO)", "methodology": "fee schedule", "standard_charge_dollar": 6.52 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Commercial Ins Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.06 }, { "payer_name": "Health Net Of CA", "plan_name": "Health Net Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Imperial Health Plan Of CA", "plan_name": "Imperial Health Plan Of CA Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.92, "additional_payer_notes": "106.00% of Medicare Rates" }, { "payer_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE", "plan_name": "INLAND EMPIRE FOUNDATION FOR MEDICAL CARE Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Exchange", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Molina", "plan_name": "Molina Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Molina", "plan_name": "Molina Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Neighborhood", "plan_name": "Neighborhood Medicare Pace", "methodology": "fee schedule", "standard_charge_dollar": 4.73, "additional_payer_notes": "102.00% of Medicare Rates" }, { "payer_name": "Renal Payor Solution", "plan_name": "Renal Payor Solution Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "RIOS", "plan_name": "RIOS Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.41, "additional_payer_notes": "95.00% of Medicare Rates" }, { "payer_name": "Traditional Medi-Cal", "plan_name": "Traditional Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Traditional Medicare", "plan_name": "Traditional Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Tricare", "plan_name": "Tricare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.73 }, { "payer_name": "Vantage Care", "plan_name": "Vantage Care Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Worker Compensation", "plan_name": "Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 6.11, "additional_payer_notes": "131.74% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 5.8, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 6.86 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.57 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "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": 4.73 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.96, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.69, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Coventry Workers Compensation", "plan_name": "Coventry Workers Compensation", "methodology": "fee schedule", "standard_charge_dollar": 5.93, "additional_payer_notes": "127.78% of Medicare Rates" }, { "payer_name": "Elite Health Plan", "plan_name": "Elite Health Plan (Medicare)", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.28, "additional_payer_notes": "200.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medi-cal", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Emanate Health", "plan_name": "Emanate Health Medicare", "methodology": "fee schedule", "standard_charge_dollar": 4.64, "additional_payer_notes": "100.00% of Medicare Rates" } ] } ] }, { "description": "Hc Assay Of Creatinine", "code_information": [ { "code": "82565", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 182.5, "discounted_cash": 5, "minimum": 4.864, "maximum": 182.5, "payers_information": [ { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Exchange", "methodology": "fee schedule", "standard_charge_dollar": 6.4, "additional_payer_notes": "125.00% of Medicare Rates" }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 7.18 }, { "payer_name": "Inland Empire Healthplan", "plan_name": "Inland Empire Healthplan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Alignment", "plan_name": "Alignment Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Anthem Blue Cross", "plan_name": "Anthem Blue Cross Medi-Cal", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "Blue Sheild Of CA TriWest Medicare", "plan_name": "Blue Sheild Of CA TriWest Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "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": 4.95 }, { "payer_name": "Brand New Day", "plan_name": "Brand New Day Exchange", "methodology": "fee schedule", "standard_charge_dollar": 7.68, "additional_payer_notes": "150.00% of Medicare Rates" }, { "payer_name": "Brand New Day", "plan_name": "Brand New Days Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.17, "additional_payer_notes": "101.00% of Medicare Rates" }, { "payer_name": "Central Health Plan", "plan_name": "Central Health Plan Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Choice Physicians Network", "plan_name": "Choice Physicians Network Medicare", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Citrus Valley Physicians Group", "plan_name": "Citrus Valley Physicians Group Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100.00% of Medicare Rates" }, { "payer_name": "Ci